Provider Demographics
NPI:1750452447
Name:LAN, WEN-CHUN JIMMY (MD, MS)
Entity Type:Individual
Prefix:
First Name:WEN-CHUN
Middle Name:JIMMY
Last Name:LAN
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 S PALISADE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5948
Mailing Address - Country:US
Mailing Address - Phone:805-739-3561
Mailing Address - Fax:805-739-3560
Practice Address - Street 1:235 S PALISADE DR
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454
Practice Address - Country:US
Practice Address - Phone:805-739-3961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA922922080N0001X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A922920Medicaid