Basic Information
| Provider Information | |||||||||
| NPI: | 1295812725 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YANG | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | WILSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | G. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12700 SOUTHFORK RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631283201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435942 | ||||||||
| FaxNumber: | 3145435947 | ||||||||
| Practice Location | |||||||||
| Address1: | 12700 SOUTHFORK RD | ||||||||
| Address2: | SUITE 200/220 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631283201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435942 | ||||||||
| FaxNumber: | 3145435947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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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 | 207R00000X | 112962 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 156440016 | 01 | MO | MEDICARE PTAN | OTHER |