Provider Demographics
NPI:1942665310
Name:WANG, XIANRUI (LAC)
Entity Type:Individual
Prefix:
First Name:XIANRUI
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:XIANRUI
Other - Middle Name:ROGER
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:43 HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1035
Mailing Address - Country:US
Mailing Address - Phone:732-788-3990
Mailing Address - Fax:
Practice Address - Street 1:1 NEW YORK PLZ
Practice Address - Street 2:THE MEDISPA NYC
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-1901
Practice Address - Country:US
Practice Address - Phone:732-788-3990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005578171100000X
NJ25MZ 00115800171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist