Provider Demographics
NPI:1053842526
Name:WANG, CHRISTINE ALICE (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ALICE
Last Name:WANG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:520-616-1442
Practice Address - Street 1:13395 N MARANA MAIN ST
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653-7008
Practice Address - Country:US
Practice Address - Phone:520-682-4111
Practice Address - Fax:520-682-3817
Is Sole Proprietor?:No
Enumeration Date:2017-03-25
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60935864207Q00000X
AZ009388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1053842526Medicaid
AZ122931Medicaid