Basic Information
| Provider Information | |||||||||
| NPI: | 1760435994 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAN | ||||||||
| FirstName: | XIAOMING | ||||||||
| MiddleName: | SHAWN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1830 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337571830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275321355 | ||||||||
| FaxNumber: | 7272664928 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 66TH ST N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337101510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275277035 | ||||||||
| FaxNumber: | 7275335993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME87645 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 267680000 | 05 | FL | MEDICAID | P00294413 | 01 | FL | RAILROAD MEDICARE NUMBER | OTHER |