Provider Demographics
NPI:1245774355
Name:KIM, JAKE (NP)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUSTAVE L. LEVY PLACE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6574
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1468 MADISON AVENUE
Practice Address - Street 2:BOX 1495
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6574
Practice Address - Country:US
Practice Address - Phone:212-241-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340534363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily