Provider Demographics
NPI:1659150043
Name:NGUYEN, KEVIN KIM (NP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:KIM
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6204 MAYFIELD AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-2371
Mailing Address - Country:US
Mailing Address - Phone:858-357-3465
Mailing Address - Fax:
Practice Address - Street 1:8733 BEVERLY BLVD STE 201
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1844
Practice Address - Country:US
Practice Address - Phone:858-357-3465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027344363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner