Provider Demographics
NPI:1467557603
Name:JIN, FAWN (DO)
Entity Type:Individual
Prefix:
First Name:FAWN
Middle Name:
Last Name:JIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:10060 REGENCY CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3732
Practice Address - Country:US
Practice Address - Phone:402-354-1580
Practice Address - Fax:402-354-1409
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44764207R00000X
NE716207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068731742Medicaid
IA1467557603Medicaid
NE099099073Medicare PIN