Provider Demographics
NPI:1518747609
Name:WANG, WAN
Entity type:Individual
Prefix:
First Name:WAN
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 WATERSIDE RD
Mailing Address - Street 2:
Mailing Address - City:PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23875-1265
Mailing Address - Country:US
Mailing Address - Phone:804-287-2020
Mailing Address - Fax:047-337-3908
Practice Address - Street 1:2015 WATERSIDE RD
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1265
Practice Address - Country:US
Practice Address - Phone:804-287-2020
Practice Address - Fax:804-733-7390
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1518747609152W00000X, 152WC0802X
VAPENDING152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management