Provider Demographics
NPI:1457390197
Name:WANG, FU NAN (MD)
Entity Type:Individual
Prefix:MR
First Name:FU NAN
Middle Name:
Last Name:WANG
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 1:1201 S HACIENDA BLVD
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-2232
Mailing Address - Country:US
Mailing Address - Phone:626-336-6368
Mailing Address - Fax:626-336-2152
Practice Address - Street 1:1201 S HACIENDA BLVD
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-2232
Practice Address - Country:US
Practice Address - Phone:626-336-6368
Practice Address - Fax:626-336-2152
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93089208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
A93089Medicare UPIN
I44054Medicare UPIN