Provider Demographics
NPI:1891138699
Name:WANG, NICHOLE ATSUKO (DO)
Entity Type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:ATSUKO
Last Name:WANG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:ATSUKO
Other - Last Name:MCCALVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2350 W EL CAMINO REAL
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:795 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301-2302
Practice Address - Country:US
Practice Address - Phone:650-321-4121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13643208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics