Provider Demographics
NPI:1518540640
Name:KANG, DAMISA
Entity Type:Individual
Prefix:
First Name:DAMISA
Middle Name:
Last Name:KANG
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 1:15 W 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2236
Mailing Address - Country:US
Mailing Address - Phone:650-518-8666
Mailing Address - Fax:
Practice Address - Street 1:15 W 25TH AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2236
Practice Address - Country:US
Practice Address - Phone:650-518-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79486225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist