Provider Demographics
NPI:1063457539
Name:KWAN, WAN FUNG (MD)
Entity Type:Individual
Prefix:
First Name:WAN
Middle Name:FUNG
Last Name:KWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:W
Other - Last Name:KWAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:427 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-5210
Mailing Address - Country:US
Mailing Address - Phone:256-543-3508
Mailing Address - Fax:256-543-3506
Practice Address - Street 1:427 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-5210
Practice Address - Country:US
Practice Address - Phone:256-543-3508
Practice Address - Fax:256-543-3506
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18372174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALG00488Medicare UPIN