Provider Demographics
NPI:1124589411
Name:WANG, THERESA NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:NICOLE
Last Name:WANG
Suffix:
Gender:F
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:UNIVERSITY OF WASHINGTON DEPARTMENT OF SURGERY
Mailing Address - Street 2:1959 NE PACIFIC ST
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:395 W 12TH AVE # 670
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1267
Practice Address - Country:US
Practice Address - Phone:614-293-8701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2020-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH57.249149Medicaid