Provider Demographics
NPI:1295835718
Name:FANG, JIN (ACUPUNCTURIST)
Entity Type:Individual
Prefix:MRS
First Name:JIN
Middle Name:
Last Name:FANG
Suffix:
Gender:F
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 PINEVIEW TER
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-6044
Mailing Address - Country:US
Mailing Address - Phone:607-272-4262
Mailing Address - Fax:
Practice Address - Street 1:6605 PITTSFORD PALMYRA RD
Practice Address - Street 2:BLACKWATCH OFFICE PARK E-2
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3407
Practice Address - Country:US
Practice Address - Phone:585-223-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000333171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000333OtherACUPUNCTURE
NY000852OtherACUPUNCTURE