Provider Demographics
NPI:1851195325
Name:WANG, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WANG
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E10805 W HILLSDALE DR
Mailing Address - Street 2:
Mailing Address - City:FALL CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54742-4122
Mailing Address - Country:US
Mailing Address - Phone:715-797-3790
Mailing Address - Fax:
Practice Address - Street 1:E10805 W HILLSDALE DR
Practice Address - Street 2:
Practice Address - City:FALL CREEK
Practice Address - State:WI
Practice Address - Zip Code:54742-4122
Practice Address - Country:US
Practice Address - Phone:715-797-3790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty