Provider Demographics
NPI:1245792530
Name:WANG, SHIYU
Entity Type:Individual
Prefix:
First Name:SHIYU
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 NIGHT HAWK LN
Mailing Address - Street 2:
Mailing Address - City:SANDY HOOK
Mailing Address - State:CT
Mailing Address - Zip Code:06482-1591
Mailing Address - Country:US
Mailing Address - Phone:734-474-8717
Mailing Address - Fax:
Practice Address - Street 1:900 CENTENNIAL BLVD STE 203
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4637
Practice Address - Country:US
Practice Address - Phone:856-325-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA11480400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program