Provider Demographics
NPI:1306231352
Name:XU, SHI YAN (LAC)
Entity Type:Individual
Prefix:MR
First Name:SHI YAN
Middle Name:
Last Name:XU
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 TAGUS ST.
Mailing Address - Street 2:#27
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660
Mailing Address - Country:US
Mailing Address - Phone:626-203-7966
Mailing Address - Fax:
Practice Address - Street 1:9900 TAGUS ST.
Practice Address - Street 2:#27
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660
Practice Address - Country:US
Practice Address - Phone:626-203-7966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15849171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist