Basic Information
| Provider Information | |||||||||
| NPI: | 1972525194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 WOODMONT BLVD STE LL50 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372052382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153862361 | ||||||||
| FaxNumber: | 6153862399 | ||||||||
| Practice Location | |||||||||
| Address1: | 2010 CHURCH ST STE 420 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372032037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153292141 | ||||||||
| FaxNumber: | 6153210522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | P1245 | TX | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | ME92311 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 39750 | TN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | ME92311 | 01 | FL | FLORIDA LICENSE | OTHER | Q018779 | 05 | TN | MEDICAID |