Provider Demographics
NPI:1336200443
Name:KO, SYNG WAN (LAC)
Entity Type:Individual
Prefix:
First Name:SYNG WAN
Middle Name:
Last Name:KO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1931 N GAFFEY ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-1265
Mailing Address - Country:US
Mailing Address - Phone:562-253-5055
Mailing Address - Fax:714-680-3463
Practice Address - Street 1:1931 N GAFFEY ST
Practice Address - Street 2:SUITE C
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-1265
Practice Address - Country:US
Practice Address - Phone:562-253-5055
Practice Address - Fax:714-680-3463
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA6239171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist