Provider Demographics
NPI:1982651485
Name:MICHAEL WAN, M.D., F.A.C.O.G.
Entity Type:Organization
Organization Name:MICHAEL WAN, M.D., F.A.C.O.G.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OBSTETRICS AND GYNECOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-546-6600
Mailing Address - Street 1:11100 WARNER AVE
Mailing Address - Street 2:150B
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7506
Mailing Address - Country:US
Mailing Address - Phone:714-546-6600
Mailing Address - Fax:
Practice Address - Street 1:11100 WARNER AVE
Practice Address - Street 2:150B
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7506
Practice Address - Country:US
Practice Address - Phone:714-546-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36431305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA28086Medicare UPIN
MWA36431Medicare ID - Type Unspecified