Provider Demographics
NPI:1265469274
Name:WANG, LUQIU (PAC)
Entity Type:Individual
Prefix:
First Name:LUQIU
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E BEVERLY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4300
Mailing Address - Country:US
Mailing Address - Phone:323-726-7535
Mailing Address - Fax:323-726-2544
Practice Address - Street 1:416 W LAS TUNAS DR
Practice Address - Street 2:SUITE 205
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1236
Practice Address - Country:US
Practice Address - Phone:626-285-4094
Practice Address - Fax:626-281-0025
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17198Medicaid
CAWPA17198EMedicare PIN
CAWPA17198DMedicare PIN
CAPA17198Medicaid