Provider Demographics
NPI:1265509996
Name:LU, YANG T (LIC AC)
Entity Type:Individual
Prefix:
First Name:YANG
Middle Name:T
Last Name:LU
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 WILDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1859
Mailing Address - Country:US
Mailing Address - Phone:781-894-5047
Mailing Address - Fax:
Practice Address - Street 1:74 WILDWOOD LN
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1859
Practice Address - Country:US
Practice Address - Phone:781-894-5047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA303171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist