Provider Demographics
NPI:1316626914
Name:LACSON, YAN MA (CMT)
Entity type:Individual
Prefix:
First Name:YAN
Middle Name:MA
Last Name:LACSON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 SHAW AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-3949
Mailing Address - Country:US
Mailing Address - Phone:559-939-1226
Mailing Address - Fax:
Practice Address - Street 1:1385 SHAW AVE STE 102
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3949
Practice Address - Country:US
Practice Address - Phone:559-939-1226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89475225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty