Provider Demographics
NPI: | 1093205676 |
---|---|
Name: | KIM, HONG |
Entity Type: | Individual |
Prefix: | |
First Name: | HONG |
Middle Name: | |
Last Name: | KIM |
Suffix: | |
Gender: | M |
Credentials: | |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 136 MADISON AVE FL 6 |
Mailing Address - Street 2: | |
Mailing Address - City: | NEW YORK |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 10016-6795 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 917-727-6576 |
Mailing Address - Fax: | 212-202-7873 |
Practice Address - Street 1: | 136 MADISON AVE FL 6 |
Practice Address - Street 2: | |
Practice Address - City: | NEW YORK |
Practice Address - State: | NY |
Practice Address - Zip Code: | 10016-6795 |
Practice Address - Country: | US |
Practice Address - Phone: | 917-727-6576 |
Practice Address - Fax: | 212-202-7873 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2018-05-18 |
Last Update Date: | 2023-06-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | 11013838 | 363LP0808X |
NJ | 26NJ01170200 | 363LP0808X |
NY | 711302 | 163WH0200X |
NY | 402766 | 363LP0808X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health |
No | 163WH0200X | Nursing Service Providers | Registered Nurse | Home Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
9930425 | Other | 9930425 |