Provider Demographics
NPI:1679647366
Name:WANG, TAI-NAN (LAC, OMD, QME)
Entity Type:Individual
Prefix:MR
First Name:TAI-NAN
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:LAC, OMD, QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4295 GESNER ST
Mailing Address - Street 2:STE 1A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6647
Mailing Address - Country:US
Mailing Address - Phone:858-483-7795
Mailing Address - Fax:619-276-7937
Practice Address - Street 1:4295 GESNER ST
Practice Address - Street 2:STE 1A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6647
Practice Address - Country:US
Practice Address - Phone:858-483-7795
Practice Address - Fax:619-276-7937
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 537171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0062275OtherTAX ID