Provider Demographics
NPI:1033462668
Name:WANG, SAMUEL (LAC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 5TH AVE REAR C
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3257
Mailing Address - Country:US
Mailing Address - Phone:415-485-5834
Mailing Address - Fax:415-456-2636
Practice Address - Street 1:824 5TH AVE REAR C
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3257
Practice Address - Country:US
Practice Address - Phone:415-485-5834
Practice Address - Fax:415-456-2636
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA1592171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942971531OtherL.AC.