Basic Information
| Provider Information | |||||||||
| NPI: | 1326029513 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | JEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 N 39TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156154949 | ||||||||
| FaxNumber: | 2152434649 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 N 39TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156154949 | ||||||||
| FaxNumber: | 2152434649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 10/22/2019 | ||||||||
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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 | 208600000X | MD431585 | PA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | MD431585 | PA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.