Provider Demographics
NPI:1922092659
Name:LIN, WU JAN (MD)
Entity Type:Individual
Prefix:
First Name:WU
Middle Name:JAN
Last Name:LIN
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 1:761 JOHNSONBURG RD
Mailing Address - Street 2:
Mailing Address - City:ST MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-3483
Mailing Address - Country:US
Mailing Address - Phone:814-834-1020
Mailing Address - Fax:814-834-1040
Practice Address - Street 1:763 JOHNSONBURG RD
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-3417
Practice Address - Country:US
Practice Address - Phone:814-834-1020
Practice Address - Fax:814-834-1040
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2012-10-11
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
PAMD019839E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006421100002Medicaid
PA069598OtherBLUE SHIELD
PA069598OtherBLUE SHIELD