Provider Demographics
NPI:1427412535
Name:FAN, XIAOWEN (MD)
Entity Type:Individual
Prefix:
First Name:XIAOWEN
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1915
Mailing Address - Country:US
Mailing Address - Phone:551-996-4466
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1915
Practice Address - Country:US
Practice Address - Phone:212-523-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA10564000208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program