Provider Demographics
NPI:1770258246
Name:MCCOY, GAZANIA CLARISSA (LAC)
Entity Type:Individual
Prefix:
First Name:GAZANIA
Middle Name:CLARISSA
Last Name:MCCOY
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 1:933 MACARTHUR BLVD STE 1G
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-3062
Mailing Address - Country:US
Mailing Address - Phone:510-456-0048
Mailing Address - Fax:
Practice Address - Street 1:933 MACARTHUR BLVD STE 1G
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-3062
Practice Address - Country:US
Practice Address - Phone:510-456-0048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19227171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist