Provider Demographics
NPI:1467854497
Name:WANG, SANDY (NP)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13700 MARINA POINTE DR UNIT 1625
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-9272
Mailing Address - Country:US
Mailing Address - Phone:909-319-2280
Mailing Address - Fax:
Practice Address - Street 1:13171 MINDANAO WAY
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6307
Practice Address - Country:US
Practice Address - Phone:310-821-8908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95001187363LF0000X
CA1467854497363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily