Provider Demographics
NPI:1295892362
Name:SHAO, SUSAN (LAC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:SHAO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:SC
Other - Last Name:SHAO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:9092 TALBERT AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4452
Mailing Address - Country:US
Mailing Address - Phone:714-968-3325
Mailing Address - Fax:714-968-6656
Practice Address - Street 1:9092 TALBERT AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4452
Practice Address - Country:US
Practice Address - Phone:714-968-3325
Practice Address - Fax:714-968-6656
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC2948171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA0029480OtherBLUE SHIELD OF CALIFORNIA
UT5761398OtherCOVENTRY HEALTH CARE/FIRST HEALTH