Provider Demographics
NPI:1386840932
Name:YOM, KI SUK (MS)
Entity Type:Individual
Prefix:
First Name:KI SUK
Middle Name:
Last Name:YOM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KISUK
Other - Middle Name:
Other - Last Name:YOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:14351 ROOSEVELT AVE
Mailing Address - Street 2:1F
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-6155
Mailing Address - Country:US
Mailing Address - Phone:718-661-4130
Mailing Address - Fax:718-661-4132
Practice Address - Street 1:19505 NORTHERN BLVD # 2F
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-3034
Practice Address - Country:US
Practice Address - Phone:718-661-4130
Practice Address - Fax:718-661-4132
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01321528OtherAMERIGROUP
NY03103959Medicaid
NYG300000160Medicare PIN