Provider Demographics
NPI:1760045355
Name:WANG, JIASEN (MD)
Entity Type:Individual
Prefix:
First Name:JIASEN
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 RANCH RD. 2222, BLDG 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-3255
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:
Practice Address - Street 1:8316 KASEMAN CT NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7639
Practice Address - Country:US
Practice Address - Phone:505-292-5850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2023-1076207N00000X
CAA186212207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology