Provider Demographics
NPI:1497891709
Name:WAN, SAM (ACUPUNCTURIST)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:WAN
Suffix:
Gender:M
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 SUNRISE AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4123
Mailing Address - Country:US
Mailing Address - Phone:916-783-3003
Mailing Address - Fax:916-783-4799
Practice Address - Street 1:408 SUNRISE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4123
Practice Address - Country:US
Practice Address - Phone:916-783-3003
Practice Address - Fax:916-783-4799
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC218171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist