Provider Demographics
NPI:1497042774
Name:WANG, CALREN S (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CALREN
Middle Name:S
Last Name:WANG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CALLY
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MMS, PA-C
Mailing Address - Street 1:1715 STAFFORD DR
Mailing Address - Street 2:
Mailing Address - City:BELLE ISLE
Mailing Address - State:FL
Mailing Address - Zip Code:32809-6862
Mailing Address - Country:US
Mailing Address - Phone:228-224-1160
Mailing Address - Fax:
Practice Address - Street 1:1715 STAFFORD DR
Practice Address - Street 2:
Practice Address - City:BELLE ISLE
Practice Address - State:FL
Practice Address - Zip Code:32809-6862
Practice Address - Country:US
Practice Address - Phone:228-224-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4495225200000X
FL9113609363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant