Provider Demographics
NPI:1689291379
Name:HA, YOUNG SOO
Entity Type:Individual
Prefix:
First Name:YOUNG
Middle Name:SOO
Last Name:HA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20305 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1021
Mailing Address - Country:US
Mailing Address - Phone:718-939-6137
Mailing Address - Fax:
Practice Address - Street 1:20305 32ND AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1021
Practice Address - Country:US
Practice Address - Phone:718-939-6137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker