Provider Demographics
NPI:1114326758
Name:KIM, BYUNG GEUN (APN)
Entity Type:Individual
Prefix:
First Name:BYUNG GEUN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 W SILVER SPRING DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4217
Mailing Address - Country:US
Mailing Address - Phone:414-461-9250
Mailing Address - Fax:
Practice Address - Street 1:2501 W SILVER SPRING DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-4217
Practice Address - Country:US
Practice Address - Phone:414-461-9250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163507363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI163507OtherLICENSE