Provider Demographics
NPI:1417290248
Name:WANG, YI
Entity Type:Individual
Prefix:
First Name:YI
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 1:2970 W US HIGHWAY 90 STE 110
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4703
Mailing Address - Country:US
Mailing Address - Phone:386-247-6915
Mailing Address - Fax:
Practice Address - Street 1:2970 W US HIGHWAY 90 STE 110
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4703
Practice Address - Country:US
Practice Address - Phone:386-247-6915
Practice Address - Fax:386-247-6915
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101258942208600000X
PAMT216590390200000X
FL136863208600000X
PAMT216950208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program