Provider Demographics
NPI:1174795041
Name:FANG, FANNIE H (MD)
Entity type:Individual
Prefix:
First Name:FANNIE
Middle Name:H
Last Name:FANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HIU-PUI
Other - Middle Name:
Other - Last Name:LAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1001 JONES ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-5512
Mailing Address - Country:US
Mailing Address - Phone:775-322-1880
Mailing Address - Fax:775-322-1987
Practice Address - Street 1:1001 JONES ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-5512
Practice Address - Country:US
Practice Address - Phone:775-322-1880
Practice Address - Fax:775-322-1987
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16196208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016499Medicaid