Provider Demographics
NPI:1174901003
Name:WANG, QIUJUAN (PA)
Entity type:Individual
Prefix:
First Name:QIUJUAN
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 CELEBRATION PL STE A290
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-4970
Mailing Address - Country:US
Mailing Address - Phone:407-303-3827
Mailing Address - Fax:407-303-3828
Practice Address - Street 1:285 E STATE ST STE 400
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4368
Practice Address - Country:US
Practice Address - Phone:614-566-7370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60989637363A00000X
NY018589363A00000X
VA0110006085363A00000X
FLPA9113633363A00000X
OH004328363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05382861Medicaid