Provider Demographics
NPI:1619390630
Name:BAE, JI SEON
Entity Type:Individual
Prefix:
First Name:JI SEON
Middle Name:
Last Name:BAE
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 1:5830 BONFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-1120
Mailing Address - Country:US
Mailing Address - Phone:562-889-8787
Mailing Address - Fax:
Practice Address - Street 1:23517 MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-5234
Practice Address - Country:US
Practice Address - Phone:562-889-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23263363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily