Provider Demographics
NPI:1679787766
Name:KIM, MOON JU (NP)
Entity type:Individual
Prefix:
First Name:MOON
Middle Name:JU
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2721
Mailing Address - Country:US
Mailing Address - Phone:213-380-8833
Mailing Address - Fax:213-368-6047
Practice Address - Street 1:1058 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2721
Practice Address - Country:US
Practice Address - Phone:213-380-8833
Practice Address - Fax:213-368-6047
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP8434363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP0084340Medicaid