Basic Information
| Provider Information | |||||||||
| NPI: | 1164607461 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | TISHA | ||||||||
| MiddleName: | SHIH-YUN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD | ||||||||
| Address2: | SUITE # 200 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108255316 | ||||||||
| FaxNumber: | 3102068622 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MEDICAL PLAZA | ||||||||
| Address2: | SUITE # 365, 530, 420, 250 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102066232 | ||||||||
| FaxNumber: | 3102068622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2008 | ||||||||
| LastUpdateDate: | 07/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | A86107 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | A86107 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | A86107 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | A86107 | 01 | CA | MEDICAL LICENSE | OTHER | 00A861070 | 05 | CA | MEDICAID | 1164607461 | 01 | CA | CCS PANELED | OTHER |