Provider Demographics
NPI:1902391832
Name:WANG, LI (LAC)
Entity Type:Individual
Prefix:
First Name:LI
Middle Name:
Last Name:WANG
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 1:3165 138TH ST APT 3G
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-2636
Mailing Address - Country:US
Mailing Address - Phone:646-708-3593
Mailing Address - Fax:
Practice Address - Street 1:15 PARK AVE STE 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4348
Practice Address - Country:US
Practice Address - Phone:646-708-3593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-23
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006123-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY890646420OtherTHE EMPIRE PLAN