Provider Demographics
NPI:1053133017
Name:KIM, MYUNG (NP)
Entity type:Individual
Prefix:
First Name:MYUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:942 W VALENCIA MESA DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4010
Mailing Address - Country:US
Mailing Address - Phone:917-865-8271
Mailing Address - Fax:
Practice Address - Street 1:623 N WOOD AVE # 6B
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-4151
Practice Address - Country:US
Practice Address - Phone:908-486-0990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95318198363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology