Basic Information
| Provider Information | |||||||||
| NPI: | 1912988486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | KE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 MOUNT AUBURN ST | ||||||||
| Address2: | DOB 316 | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021385600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174976058 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 MOUNT AUBURN ST | ||||||||
| Address2: | DOB 316 | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021385600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174976058 | ||||||||
| FaxNumber: | 6174995441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 07/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 210278 | MA | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0134805 | 05 | MA | MEDICAID |