Provider Demographics
NPI: | 1952462905 |
---|---|
Name: | WU, SHAWN X (MD) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | SHAWN |
Middle Name: | X |
Last Name: | WU |
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: | 14986 ANGELA DR |
Mailing Address - Street 2: | |
Mailing Address - City: | GULFPORT |
Mailing Address - State: | MS |
Mailing Address - Zip Code: | 39503-3502 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 228-357-5464 |
Mailing Address - Fax: | 877-563-0603 |
Practice Address - Street 1: | 14986 ANGELA DR |
Practice Address - Street 2: | |
Practice Address - City: | GULFPORT |
Practice Address - State: | MS |
Practice Address - Zip Code: | 39503-3502 |
Practice Address - Country: | US |
Practice Address - Phone: | 228-357-5464 |
Practice Address - Fax: | 877-563-0603 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-12-13 |
Last Update Date: | 2020-10-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MS | 18988 | 208100000X, 208VP0014X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208VP0014X | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MS | 00002077 | Medicaid | |
MS | 250000069 | Medicare ID - Type Unspecified | |
MS | 00002077 | Medicaid |