Provider Demographics
NPI:1043220098
Name:KO, YONGSOON (NP)
Entity Type:Individual
Prefix:
First Name:YONGSOON
Middle Name:
Last Name:KO
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 1:230 E RIDGEWOOD AVE
Mailing Address - Street 2:BERGEN REGIONAL MEDICAL CENTER
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-4142
Mailing Address - Country:US
Mailing Address - Phone:201-207-9557
Mailing Address - Fax:201-784-1136
Practice Address - Street 1:230 E. RIDGEWOOD AVE
Practice Address - Street 2:BERGEN REGIONAL MEDICAL CENTER
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-4142
Practice Address - Country:US
Practice Address - Phone:201-207-9557
Practice Address - Fax:201-784-1136
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303116-1363L00000X
NJ26NN07873000363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02196743Medicaid
2E4401Medicare ID - Type Unspecified
NY02196743Medicaid