Basic Information
| Provider Information | |||||||||
| NPI: | 1295132785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | LI | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1821 MARTIN LUTHER KING PKWY # 100277 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277076336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307400574 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1821 MARTIN LUTHER KING PKWY # 100277 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307400574 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2014 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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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 | 363LF0000X | ARNP9339187 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | ARNP9339187 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 013939400 | 05 | FL | MEDICAID |