Provider Demographics
NPI:1467817825
Name:WANG, JACK
Entity Type:Individual
Prefix:
First Name:JACK
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 1:1821 N TREKELL RD STE 7
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-1705
Mailing Address - Country:US
Mailing Address - Phone:520-876-9293
Mailing Address - Fax:520-876-9334
Practice Address - Street 1:1821 N TREKELL RD
Practice Address - Street 2:STE 7
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-1705
Practice Address - Country:US
Practice Address - Phone:520-876-9293
Practice Address - Fax:520-876-9334
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist