Provider Demographics
NPI:1336022839
Name:WANG, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39141 CIVIC CENTER DR STE 120
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-5831
Mailing Address - Country:US
Mailing Address - Phone:510-794-9672
Mailing Address - Fax:
Practice Address - Street 1:39141 CIVIC CENTER DR STE 120
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-5831
Practice Address - Country:US
Practice Address - Phone:510-794-9672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-30
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA308417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist