Provider Demographics
NPI:1497306716
Name:WAN, FANG (LAC)
Entity Type:Individual
Prefix:
First Name:FANG
Middle Name:
Last Name:WAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13900 DULUTH DR
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-9206
Mailing Address - Country:US
Mailing Address - Phone:651-444-9797
Mailing Address - Fax:
Practice Address - Street 1:7373 147TH ST W STE 176
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-8157
Practice Address - Country:US
Practice Address - Phone:651-444-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1776171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist