Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 95002105 | CA |
NPI | 1003299033 |
---|---|
Provider Name | Jessica Wang |
First Address | West Covina, CA 91792-2517 |
Second Address | San Gabriel, CA 91776-6510 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2015 |
Last Update Date | 08/07/2015 |