Basic Information
| Provider Information | |||||||||
| NPI: | 1528074705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TSAI | ||||||||
| FirstName: | WAN | ||||||||
| MiddleName: | CHONG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHONG | ||||||||
| OtherFirstName: | WAN | ||||||||
| OtherMiddleName: | CHUEN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD # A201 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178842976 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 S HAGADORN RD | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178848600 | ||||||||
| FaxNumber: | 5178848650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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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 | 208000000X | 4301062502 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0214X | 4301062502 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | 2080P0214X | 35096852 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 07089 | 01 | OH | PARAMOUNT | OTHER | 5243688 | 01 | OH | AETNA | OTHER | 3515022 | 05 | MI | MEDICAID | 2083392 | 05 | OH | MEDICAID | 1528074705 | 05 | MI | MEDICAID |