Provider Demographics
NPI:1851445654
Name:WONG, BAN BAN (LAC)
Entity Type:Individual
Prefix:
First Name:BAN
Middle Name:BAN
Last Name:WONG
Suffix:
Gender:M
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:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3055 ROSLYN ST UNIT 250
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-2778
Practice Address - Country:US
Practice Address - Phone:720-553-2750
Practice Address - Fax:720-553-2763
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0001234171100000X
CAAC6485171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist