Provider Demographics
NPI:1750820015
Name:KIM, NAM SU
Entity Type:Individual
Prefix:
First Name:NAM SU
Middle Name:
Last Name:KIM
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 1:1627 S 312TH ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-4915
Mailing Address - Country:US
Mailing Address - Phone:253-839-9330
Mailing Address - Fax:425-644-6067
Practice Address - Street 1:1627 S 312TH ST UNIT B
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4915
Practice Address - Country:US
Practice Address - Phone:253-839-9330
Practice Address - Fax:425-644-6067
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60726687225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist