Provider Demographics
NPI:1194224261
Name:FU, BOMAEN
Entity Type:Individual
Prefix:
First Name:BOMAEN
Middle Name:
Last Name:FU
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 1:5259 79TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4156
Mailing Address - Country:US
Mailing Address - Phone:917-518-0892
Mailing Address - Fax:
Practice Address - Street 1:230 GRAND ST STE 403B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4241
Practice Address - Country:US
Practice Address - Phone:917-518-0892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03081171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist