Provider Demographics
NPI:1508102336
Name:WANG, PIN WEN
Entity Type:Individual
Prefix:
First Name:PIN WEN
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10604 N TRADEMARK PKWY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5938
Mailing Address - Country:US
Mailing Address - Phone:909-476-5747
Mailing Address - Fax:
Practice Address - Street 1:10604 N TRADEMARK PKWY
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5938
Practice Address - Country:US
Practice Address - Phone:909-476-5747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-26
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15168225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics