Provider Demographics
NPI:1710764550
Name:KIM, JU YEON
Entity Type:Individual
Prefix:
First Name:JU
Middle Name:YEON
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JU
Other - Middle Name:YEON
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8161 GATEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-6905
Mailing Address - Country:US
Mailing Address - Phone:315-414-6305
Mailing Address - Fax:
Practice Address - Street 1:4000 MEDICAL CENTER
Practice Address - Street 2:SUITE 212
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066
Practice Address - Country:US
Practice Address - Phone:315-744-1570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY351939363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily