Provider Demographics
NPI:1548577232
Name:LOU, GIN WEN
Entity type:Individual
Prefix:
First Name:GIN
Middle Name:WEN
Last Name:LOU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3614 S PROVIDENCE RD STE 200
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6310
Practice Address - Country:US
Practice Address - Phone:704-384-8640
Practice Address - Fax:704-384-8650
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00453207Q00000X, 207Q00000X
NY268043207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03531615Medicaid
NC1548577232Medicaid
SCNC2641Medicaid
VAGC1100Medicare PIN
NYJ400084017Medicare PIN
NCNCR798CMedicare UPIN
NY03531615Medicaid
SCNC2641Medicaid
NCNCR798DMedicare UPIN