Provider Demographics
NPI:1659724839
Name:CHUNG, KEVIN MINWOO (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MINWOO
Last Name:CHUNG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 OAK GROVE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4813
Mailing Address - Country:US
Mailing Address - Phone:571-334-6061
Mailing Address - Fax:
Practice Address - Street 1:2010 BALDWIN LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5846
Practice Address - Country:US
Practice Address - Phone:336-277-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant