Provider Demographics
NPI:1164103123
Name:YOUM, MINA
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:YOUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RIVERFRONT BLVD APT 1333
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-1670
Mailing Address - Country:US
Mailing Address - Phone:201-874-3779
Mailing Address - Fax:
Practice Address - Street 1:233 LAFAYETTE AVE STE LL5
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4822
Practice Address - Country:US
Practice Address - Phone:845-357-5775
Practice Address - Fax:845-357-5777
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR19027900163W00000X, 367500000X
NY720775367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse