Basic Information
| Provider Information | |||||||||
| NPI: | 1407306152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | EMMA | ||||||||
| MiddleName: | MINGZHU | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WANG | ||||||||
| OtherFirstName: | MINGZHU | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 136-26 37TH AVENUE | ||||||||
| Address2: | CBWCHC | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113543746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188861212 | ||||||||
| FaxNumber: | 7188862568 | ||||||||
| Practice Location | |||||||||
| Address1: | 136-26 37TH AVENUE | ||||||||
| Address2: | CBWCHC | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113543746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188861212 | ||||||||
| FaxNumber: | 7188862568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2016 | ||||||||
| LastUpdateDate: | 10/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 721362 | NY | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | PW66993N | 05 | NY | MEDICAID |