Provider Demographics
NPI:1598916371
Name:RUCKER, KIM PYOUNGSOON (NP)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:PYOUNGSOON
Last Name:RUCKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25222 E INDORE DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-2188
Mailing Address - Country:US
Mailing Address - Phone:303-699-4885
Mailing Address - Fax:
Practice Address - Street 1:1055 CLERMONT ST
Practice Address - Street 2:DENVER VA MEDICAL CENTER, AMBULARTORY CARE (11B)
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3808
Practice Address - Country:US
Practice Address - Phone:303-399-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2010-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO89129363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily