Provider Demographics
NPI:1558909705
Name:SHIN, ALBERT J
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:J
Last Name:SHIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 FAIR OAKS AVE APT 23
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4735
Mailing Address - Country:US
Mailing Address - Phone:626-787-3237
Mailing Address - Fax:
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-880-7812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-18
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA792313163WC0200X
CA95012670363LA2100X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty