Provider Demographics
NPI:1720567613
Name:SON, MIAE (LAC)
Entity Type:Individual
Prefix:
First Name:MIAE
Middle Name:
Last Name:SON
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 1:55 WINDMILL CT
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1942
Mailing Address - Country:US
Mailing Address - Phone:646-267-9332
Mailing Address - Fax:
Practice Address - Street 1:253-02 W END DR,
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-1174
Practice Address - Country:US
Practice Address - Phone:646-267-9332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00611171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist