Provider Demographics
NPI:1487841755
Name:KIM, LIZIA K (PA-C)
Entity Type:Individual
Prefix:
First Name:LIZIA
Middle Name:K
Last Name:KIM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 LAKEVILLE RD
Mailing Address - Street 2:206
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1101
Mailing Address - Country:US
Mailing Address - Phone:718-470-7644
Mailing Address - Fax:
Practice Address - Street 1:410 LAKEVILLE RD
Practice Address - Street 2:206
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1101
Practice Address - Country:US
Practice Address - Phone:718-470-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant