Provider Demographics
NPI:1356497481
Name:FAN, YALI (DOM)
Entity Type:Individual
Prefix:DR
First Name:YALI
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 WEBB RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615
Mailing Address - Country:US
Mailing Address - Phone:813-882-8373
Mailing Address - Fax:
Practice Address - Street 1:5905 WEBB RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615
Practice Address - Country:US
Practice Address - Phone:813-882-8373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 862171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist