Provider Demographics
NPI:1609356823
Name:WAKAO, YUTA
Entity Type:Individual
Prefix:
First Name:YUTA
Middle Name:
Last Name:WAKAO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6585 REFLECTION DR APT 104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3118
Mailing Address - Country:US
Mailing Address - Phone:619-846-2837
Mailing Address - Fax:
Practice Address - Street 1:3505 CAMINO DEL RIO S STE 338
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4017
Practice Address - Country:US
Practice Address - Phone:619-550-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18167171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist