Provider Demographics
NPI:1760435994
Name:WAN, XIAOMING SHAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:XIAOMING
Middle Name:SHAWN
Last Name:WAN
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:PO BOX 1830
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-1830
Mailing Address - Country:US
Mailing Address - Phone:727-532-1355
Mailing Address - Fax:727-266-4928
Practice Address - Street 1:3201 66TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1510
Practice Address - Country:US
Practice Address - Phone:727-527-7035
Practice Address - Fax:727-533-5993
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87645207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267680000Medicaid
FLP00294413OtherRAILROAD MEDICARE NUMBER
FL267680000Medicaid
FLU0936VMedicare PIN
FLP00294413OtherRAILROAD MEDICARE NUMBER
FLU0936UMedicare PIN