Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 70000 | GA |
N | 208600000X | Surgeon | 70000 | GA |
N | 208200000X | Surgeon | MT188087 | PA |
N | 208600000X | Surgeon | MT188087 | PA |
Y | 2086S0122X | Plastic and Reconstructive Surgery | 070000 | GA |
NPI | 1023174901 |
---|---|
Provider Name | Theresa Wang |
First Address | Atlanta, GA 30305-3611 |
Second Address | Atlanta, GA 30327-2308 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/12/2006 |
Last Update Date | 29/07/2016 |