Provider Demographics
NPI:1306220462
Name:WANG, PU POLLY
Entity Type:Individual
Prefix:
First Name:PU
Middle Name:POLLY
Last Name:WANG
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 1:6513 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-4622
Mailing Address - Country:US
Mailing Address - Phone:323-888-1122
Mailing Address - Fax:
Practice Address - Street 1:511 1/2 ELIZABETH AVE
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91755-1403
Practice Address - Country:US
Practice Address - Phone:323-633-0398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11270171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA11270OtherACUPUNCTURIST