Provider Demographics
NPI:1306415914
Name:KWON, LOIS MIN JEE
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:MIN JEE
Last Name:KWON
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 1:263 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-0001
Mailing Address - Country:US
Mailing Address - Phone:860-679-2147
Mailing Address - Fax:860-679-4624
Practice Address - Street 1:263 FARMINGTON AVE # LG065
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-3031
Practice Address - Country:US
Practice Address - Phone:860-679-4988
Practice Address - Fax:860-479-3489
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6601659532Medicaid