Provider Demographics
NPI:1295707123
Name:WAN, SAN (MD)
Entity type:Individual
Prefix:
First Name:SAN
Middle Name:
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 1:8 WILDFLOWER LN
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-1167
Mailing Address - Country:US
Mailing Address - Phone:781-647-9863
Mailing Address - Fax:
Practice Address - Street 1:340 WOOD RD
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-2401
Practice Address - Country:US
Practice Address - Phone:781-849-1111
Practice Address - Fax:781-794-2280
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA46315207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
01Y000581MA01OtherANTHEM
2430963OtherAETNA
P00034200OtherRAILROAD MEDICARE
B20406102OtherCIGNA
MA0156736Medicaid
MA713618OtherTUFTS HEALTH PLANS
MA401197OtherHARVARD PILGRIM HEALTHCAR
MAB36040OtherBLUE CROSS BLUE SHIELD OF
0300380OtherUNITED HEALTHCARE
B20406102OtherCIGNA
01Y000581MA01OtherANTHEM