Provider Demographics
NPI:1164498978
Name:KIM, JAMIE (PA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:WON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 GUSTAVE L LEVY PL.
Mailing Address - Street 2:BOX 1263
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6574
Mailing Address - Country:US
Mailing Address - Phone:212-241-4585
Mailing Address - Fax:212-987-9310
Practice Address - Street 1:5 EAST 98TH STREET
Practice Address - Street 2:14TH FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6574
Practice Address - Country:US
Practice Address - Phone:212-241-4585
Practice Address - Fax:212-987-9310
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010037363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5730L1Medicare ID - Type Unspecified
Q32259Medicare UPIN