Provider Demographics
NPI:1043657497
Name:WANG, SOPHIA CHUNYUN (LAC)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:CHUNYUN
Last Name:WANG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:CHUNYUN
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:125 HADDON RD
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1740
Mailing Address - Country:US
Mailing Address - Phone:516-376-2130
Mailing Address - Fax:
Practice Address - Street 1:600 NORTHERN BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5206
Practice Address - Country:US
Practice Address - Phone:516-543-3518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004722171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist