Provider Demographics
NPI:1265761571
Name:WEGMULLER, JOHANNES KAZUO (LAC)
Entity type:Individual
Prefix:MR
First Name:JOHANNES
Middle Name:KAZUO
Last Name:WEGMULLER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:MR
Other - First Name:KAZ
Other - Middle Name:
Other - Last Name:WEGMULLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:208 ESCALONA DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2605
Mailing Address - Country:US
Mailing Address - Phone:831-706-6125
Mailing Address - Fax:
Practice Address - Street 1:208 ESCALONA DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2605
Practice Address - Country:US
Practice Address - Phone:831-706-6125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6495171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist