Provider Demographics
NPI:1124770607
Name:GU, JINGWAN
Entity type:Individual
Prefix:
First Name:JINGWAN
Middle Name:
Last Name:GU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 AVALON AVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-7302
Mailing Address - Country:US
Mailing Address - Phone:857-210-8973
Mailing Address - Fax:
Practice Address - Street 1:19 FOSTER ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1715
Practice Address - Country:US
Practice Address - Phone:774-243-3477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist