Provider Demographics
NPI:1659599389
Name:KIM, KWAN JAMES (CCP)
Entity Type:Individual
Prefix:
First Name:KWAN
Middle Name:JAMES
Last Name:KIM
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 ROCKING HORSE COURT
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568
Mailing Address - Country:US
Mailing Address - Phone:925-828-7075
Mailing Address - Fax:650-615-9995
Practice Address - Street 1:3608 ROCKING HORSE COURT
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568
Practice Address - Country:US
Practice Address - Phone:925-828-7075
Practice Address - Fax:650-615-9995
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010050242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist