Provider Demographics
NPI:1538393236
Name:WAN, JING
Entity type:Individual
Prefix:
First Name:JING
Middle Name:
Last Name:WAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 PETTIBUSH LN
Mailing Address - Street 2:
Mailing Address - City:DUXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02332-4311
Mailing Address - Country:US
Mailing Address - Phone:781-500-9161
Mailing Address - Fax:781-336-4165
Practice Address - Street 1:29 PETTIBUSH LN
Practice Address - Street 2:
Practice Address - City:DUXBURY
Practice Address - State:MA
Practice Address - Zip Code:02332-4311
Practice Address - Country:US
Practice Address - Phone:781-500-9161
Practice Address - Fax:781-336-4165
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225900171100000X
NY6473886171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist