Provider Demographics
NPI:1629543970
Name:KIM, ICK HO (NP-C)
Entity Type:Individual
Prefix:
First Name:ICK HO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21408 RABBITS GLEN CT
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-6951
Mailing Address - Country:US
Mailing Address - Phone:240-688-9899
Mailing Address - Fax:
Practice Address - Street 1:10 CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20892
Practice Address - Country:US
Practice Address - Phone:301-451-0336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR169959363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily