Provider Demographics
NPI:1679337968
Name:KONG, PAUL YEEJ (CMT, LMT)
Entity Type:Individual
Prefix:
First Name:PAUL YEEJ
Middle Name:
Last Name:KONG
Suffix:
Gender:M
Credentials:CMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 WHEELOCK PKWY E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-3008
Mailing Address - Country:US
Mailing Address - Phone:651-283-6107
Mailing Address - Fax:
Practice Address - Street 1:2353 RICE ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3739
Practice Address - Country:US
Practice Address - Phone:651-283-6107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2024350225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist