Provider Demographics
NPI:1417294315
Name:WANG, JIA (LAC)
Entity Type:Individual
Prefix:MR
First Name:JIA
Middle Name:
Last Name:WANG
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 1:4295 MAIN ST
Mailing Address - Street 2:4E
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-4786
Mailing Address - Country:US
Mailing Address - Phone:646-651-8023
Mailing Address - Fax:
Practice Address - Street 1:4295 MAIN ST
Practice Address - Street 2:4E
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-4786
Practice Address - Country:US
Practice Address - Phone:646-651-8023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0048711171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist