Basic Information
| Provider Information | |||||||||
| NPI: | 1508397175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | MIRANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8441 STATE HIGHWAY 47 STE 3115 | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778073207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9797768440 | ||||||||
| FaxNumber: | 9794360072 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 E 29TH ST | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778022622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9797768440 | ||||||||
| FaxNumber: | 8776015854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2017 | ||||||||
| LastUpdateDate: | 06/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | R9700 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.