Provider Demographics
NPI:1659080828
Name:WANG, MINNA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MINNA
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY ST STE 7B
Practice Address - Street 2:SHAPIRO BLDG.
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-3549
Practice Address - Country:US
Practice Address - Phone:617-638-8456
Practice Address - Fax:617-638-8465
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2358513363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110199270AMedicaid