Provider Demographics
NPI:1326215906
Name:WANG, XIAOFAN (LIC AC)
Entity type:Individual
Prefix:
First Name:XIAOFAN
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BRADLEY RD
Mailing Address - Street 2:#14
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-6619
Mailing Address - Country:US
Mailing Address - Phone:989-773-3789
Mailing Address - Fax:
Practice Address - Street 1:NORTH MISSION HEALTH CARE
Practice Address - Street 2:416 N. MISSION STREET
Practice Address - City:MT. PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-773-3789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA548171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist