Provider Demographics
NPI:1023116654
Name:WAN, RICHARD TC (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:TC
Last Name:WAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W ROBERTS ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42261-7942
Mailing Address - Country:US
Mailing Address - Phone:270-526-3841
Mailing Address - Fax:270-526-2651
Practice Address - Street 1:101 W ROBERTS ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:KY
Practice Address - Zip Code:42261-7942
Practice Address - Country:US
Practice Address - Phone:270-526-3841
Practice Address - Fax:270-526-2651
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16599207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64165996Medicaid
KY1229201Medicare ID - Type Unspecified
KY64165996Medicaid