Provider Demographics
NPI:1740320795
Name:WANG, JERRY (DC)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 112TH AVE NE STE C240
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3727
Mailing Address - Country:US
Mailing Address - Phone:425-688-1994
Mailing Address - Fax:425-688-1990
Practice Address - Street 1:1750 112TH AVE NE STE C240
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5233
Practice Address - Country:US
Practice Address - Phone:425-688-1994
Practice Address - Fax:425-688-1990
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3517111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB04262Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
WAU70637Medicare UPIN