Provider Demographics
NPI:1083777627
Name:SHIN, MIMIE PAK (MPT)
Entity Type:Individual
Prefix:
First Name:MIMIE
Middle Name:PAK
Last Name:SHIN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25580 VIA CAZADOR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93923-8406
Mailing Address - Country:US
Mailing Address - Phone:831-682-5014
Mailing Address - Fax:
Practice Address - Street 1:21 UPPER RAGSDALE DR
Practice Address - Street 2:SUITE #125
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-7831
Practice Address - Country:US
Practice Address - Phone:831-372-2963
Practice Address - Fax:831-656-9179
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00362453OtherMC RAILROAD PIN
CA0PT25270OtherBLUE SHIELD PIN NUMBER
CAPT25275OtherSTATE LICENSE
CAP00362453OtherMC RAILROAD PIN