Provider Demographics
NPI:1083067508
Name:WAN, NOK KEN (OD)
Entity Type:Individual
Prefix:DR
First Name:NOK KEN
Middle Name:
Last Name:WAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-5159
Mailing Address - Country:US
Mailing Address - Phone:580-225-1555
Mailing Address - Fax:
Practice Address - Street 1:1710 W 3RD ST
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-5159
Practice Address - Country:US
Practice Address - Phone:580-225-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2911152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist