Provider Demographics
NPI:1003134206
Name:FAN, SHOU-YUAN (LAC)
Entity Type:Individual
Prefix:
First Name:SHOU-YUAN
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MOUNT PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-2904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 MOUNT PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-2904
Practice Address - Country:US
Practice Address - Phone:973-350-0073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00073400171100000X
NY004232171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist