Provider Demographics
NPI:1588628788
Name:WAN, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:WAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11100 WARNER AVE
Mailing Address - Street 2:SUITE 150B
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7510
Mailing Address - Country:US
Mailing Address - Phone:714-546-6600
Mailing Address - Fax:714-546-6608
Practice Address - Street 1:11100 WARNER AVE
Practice Address - Street 2:SUITE 150B
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7510
Practice Address - Country:US
Practice Address - Phone:714-546-6600
Practice Address - Fax:714-546-6608
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA36431207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA28086Medicare UPIN