Provider Demographics
NPI:1457499543
Name:FAN, WEN (MD)
Entity Type:Individual
Prefix:
First Name:WEN
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1900 HEMPSTEAD TPKE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1702
Mailing Address - Country:US
Mailing Address - Phone:516-542-1090
Mailing Address - Fax:770-666-9097
Practice Address - Street 1:10 NATHAN D PERLMAN PLACE
Practice Address - Street 2:SUITE 12S34
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3851
Practice Address - Country:US
Practice Address - Phone:212-420-2124
Practice Address - Fax:212-420-3449
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2011-12-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY232248207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02860346Medicaid
NY3Z11275252OtherNGS
NY3Z11270211Medicare PIN
NY03Z112Medicare PIN