Provider Demographics
NPI:1144579525
Name:MARTIN, WENJUN WANG (AA)
Entity Type:Individual
Prefix:
First Name:WENJUN
Middle Name:WANG
Last Name:MARTIN
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:WENJUN
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2327
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33859-2327
Mailing Address - Country:US
Mailing Address - Phone:863-402-0064
Mailing Address - Fax:
Practice Address - Street 1:410 S 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4203
Practice Address - Country:US
Practice Address - Phone:863-402-0064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2024-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA323367H00000X
MO2012030849367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant