Provider Demographics
NPI:1174257414
Name:IM, DONGWHAN DUSTIN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:DONGWHAN
Middle Name:DUSTIN
Last Name:IM
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1000 S FREMONT AVE BLDG A-11
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-8800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 N TUSTIN AVE STE 507
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3609
Practice Address - Country:US
Practice Address - Phone:949-566-8688
Practice Address - Fax:949-566-8656
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant