Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RN0300X | Nephrologist | A119259 | CA |
NPI | 1003183617 |
---|---|
Provider Name | Jackson Wang |
First Address | Grass Valley, CA 95949-8194 |
Second Address | Grass Valley, CA 95949-8194 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2011 |
Last Update Date | 19/05/2015 |