Provider Demographics
NPI:1710942461
Name:HAN, GWANG SOO (MD)
Entity Type:Individual
Prefix:
First Name:GWANG
Middle Name:SOO
Last Name:HAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779
Mailing Address - Country:US
Mailing Address - Phone:828-586-4096
Mailing Address - Fax:828-586-1064
Practice Address - Street 1:111 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779
Practice Address - Country:US
Practice Address - Phone:828-586-4096
Practice Address - Fax:828-586-1064
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19118207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC38960OtherBCBS
NC016AVOtherBCBS GROUP
NC89016AVMedicaid
NC8938960Medicaid
NC016AVOtherBCBS GROUP
NC38960OtherBCBS
NC201515AMedicare ID - Type Unspecified