Provider Demographics
NPI:1174821128
Name:AN, YOUNGSOON
Entity Type:Individual
Prefix:
First Name:YOUNGSOON
Middle Name:
Last Name:AN
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 1:254 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-1727
Mailing Address - Country:US
Mailing Address - Phone:718-406-6705
Mailing Address - Fax:
Practice Address - Street 1:10 UNION SQ E
Practice Address - Street 2:SUITE 4G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3314
Practice Address - Country:US
Practice Address - Phone:201-866-9320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305442363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health