Provider Demographics
NPI:1588925077
Name:KOA, FANNIE TAN (LICAC, DIPLOM)
Entity type:Individual
Prefix:
First Name:FANNIE
Middle Name:TAN
Last Name:KOA
Suffix:
Gender:F
Credentials:LICAC, DIPLOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 ELM ST
Mailing Address - Street 2:SUITE 300B
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2950
Mailing Address - Country:US
Mailing Address - Phone:617-294-9109
Mailing Address - Fax:
Practice Address - Street 1:259 ELM ST
Practice Address - Street 2:SUITE 300B
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2950
Practice Address - Country:US
Practice Address - Phone:617-294-9109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA253925171100000X
NH205171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist