Provider Demographics
NPI:1528012796
Name:JIANG, WENDONG (PA-C)
Entity Type:Individual
Prefix:
First Name:WENDONG
Middle Name:
Last Name:JIANG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 N CAPITOL AVE
Practice Address - Street 2:NP E-140
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1218
Practice Address - Country:US
Practice Address - Phone:317-962-2894
Practice Address - Fax:317-963-5285
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000481A363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000506740OtherBC/BS PIN
IN200856130Medicaid
DF5450OtherRAILROAD GROUP
IN200856130Medicaid
INP01271776Medicare PIN
DF5450OtherRAILROAD GROUP
IN000000506740OtherBC/BS PIN
INP53366Medicare UPIN
IN165460LLMedicare ID - Type Unspecified