Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | A123156 | CA |
N | 207ND0900X | Dermatopathologist | A123156 | CA |
NPI | 1013206945 |
---|---|
Provider Name | Yen Tun Wang |
First Address | Glendale, CA 91204-2500 |
Second Address | Glendale, CA 91204-2500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2011 |
Last Update Date | 14/02/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A123156 | MEDICAL LICENSE (01) | CA |