Provider Demographics
NPI:1073521340
Name:SHIN, WAN (MD)
Entity Type:Individual
Prefix:DR
First Name:WAN
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:MD
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 1460
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22402-1460
Mailing Address - Country:US
Mailing Address - Phone:540-786-2100
Mailing Address - Fax:540-786-0677
Practice Address - Street 1:300 PARK HILL DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3387
Practice Address - Country:US
Practice Address - Phone:540-361-7641
Practice Address - Fax:540-361-1246
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101030663208100000X, 2081P0004X, 2081P2900X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073521340Medicaid
VA006841643Medicaid
VA1073521340Medicare PIN
194896W98Medicare ID - Type Unspecified
VA006841643Medicaid
VAVV3775AMedicare UPIN