Provider Demographics
NPI:1366562209
Name:MA, LAN (LAC)
Entity type:Individual
Prefix:MS
First Name:LAN
Middle Name:
Last Name:MA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21720 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3526
Mailing Address - Country:US
Mailing Address - Phone:646-331-1343
Mailing Address - Fax:718-229-1002
Practice Address - Street 1:5403 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-4642
Practice Address - Country:US
Practice Address - Phone:718-779-2500
Practice Address - Fax:718-779-5522
Is Sole Proprietor?:No
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002080171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist