Provider Demographics
NPI:1164878955
Name:KIM, IAN HYEON (CRNA)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:HYEON
Last Name:KIM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23455 CANDLEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1414
Mailing Address - Country:US
Mailing Address - Phone:213-400-6057
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000427367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered