Provider Demographics
NPI:1053990127
Name:KIM, ASHLEY NINA (PA)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NINA
Last Name:KIM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24221 CALLE DE LA LOUISA STE 300
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-7637
Mailing Address - Country:US
Mailing Address - Phone:949-770-7163
Mailing Address - Fax:
Practice Address - Street 1:140 E COMMONWEALTH AVE STE 100
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1905
Practice Address - Country:US
Practice Address - Phone:714-773-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA59888363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant