Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 19.15068 | IL |
Y | 208D00000X | General Practice Physician | 036.055709 | IL |
NPI | 1003043274 |
---|---|
Provider Name | Dr. William Kwok Kuen Wan |
First Address | Chicago, IL 60616 |
Second Address | Chicago, IL 60616 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2009 |
Last Update Date | 16/06/2009 |