Provider Demographics
NPI:1689917494
Name:KIM, MIA DEBORAH LEE (NP)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:DEBORAH LEE
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S MANCHESTER AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3219
Mailing Address - Country:US
Mailing Address - Phone:714-456-2986
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92697-5336
Practice Address - Country:US
Practice Address - Phone:949-824-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP22238363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner