Basic Information
| Provider Information | |||||||||
| NPI: | 1538265236 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | HOWE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 751069 | ||||||||
| Address2: | ECU PHYSICAINS | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751069 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 MOYE BLVD | ||||||||
| Address2: | ECU PHYSICIANS AT LEO W. JENKINS CANCER SERVICES | ||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278344300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527441888 | ||||||||
| FaxNumber: | 2527447005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | 2010-01582 | NC | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00533401 | 05 | HI | MEDICAID | 5915789 | 05 | NC | MEDICAID | 1590C | 01 | NC | BCBSNC | OTHER |