Provider Demographics
NPI:1154849412
Name:AN, YONG WOO (ATC)
Entity type:Individual
Prefix:PROF
First Name:YONG WOO
Middle Name:
Last Name:AN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MSC 3FAC P. O. BOX 30001
Mailing Address - Street 2:ROOM219
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88003-8001
Mailing Address - Country:US
Mailing Address - Phone:575-646-1636
Mailing Address - Fax:575-646-3564
Practice Address - Street 1:1652 STEWART ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88003
Practice Address - Country:US
Practice Address - Phone:575-646-1636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer