Provider Demographics
NPI:1528356896
Name:YOO, JAE EUN (NP)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:EUN
Last Name:YOO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JAE
Other - Middle Name:YOO
Other - Last Name:FARLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 29234
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-9234
Mailing Address - Country:US
Mailing Address - Phone:212-606-1172
Mailing Address - Fax:
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4823
Practice Address - Country:US
Practice Address - Phone:212-606-1172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY430550363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
2010009411OtherANCC
NYF430550OtherNY EDUCATION DEPARTMENT