Provider Demographics
NPI:1275658734
Name:WANG, GEORGE TIAN-YI (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:TIAN-YI
Last Name:WANG
Suffix:
Gender:M
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:PO BOX 1535
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401-1535
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-383-3553
Practice Address - Street 1:1304 FAWCETT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1911
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:253-383-3553
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010837892085D0003X, 390200000X
NC2008005242085R0202X
WAMD600715062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8882905OtherPTAN-UAOM
WA0115WAMedicare PIN
WAG8882846Medicare PIN
WACR0042Medicare PIN
WAG8883123Medicare PIN
WA8542755Medicare PIN
WAG8882845Medicare PIN
WA251879Medicare PIN
WAG8886633Medicare PIN