Provider Demographics
NPI:1972682417
Name:SHIN, MOON J (LAC)
Entity type:Individual
Prefix:MR
First Name:MOON
Middle Name:J
Last Name:SHIN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 WOODSIDE RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-5634
Mailing Address - Country:US
Mailing Address - Phone:650-556-1143
Mailing Address - Fax:650-556-0053
Practice Address - Street 1:950 WOODSIDE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94061-5634
Practice Address - Country:US
Practice Address - Phone:650-556-1143
Practice Address - Fax:650-556-0053
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9924171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist