Basic Information
| Provider Information | |||||||||
| NPI: | 1174765192 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | JINGYA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4950 ESSEN LN | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257670847 | ||||||||
| FaxNumber: | 2257660218 | ||||||||
| Practice Location | |||||||||
| Address1: | 4950 ESSEN LN | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257670847 | ||||||||
| FaxNumber: | 2257660218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2009 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
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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 | 390200000X | BP20040744 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0001X | 207864 | LA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 2393481 | 05 | LA | MEDICAID |