Provider Demographics
NPI:1760563753
Name:KIM, SUN JA (NP)
Entity Type:Individual
Prefix:MS
First Name:SUN
Middle Name:JA
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:SUN
Other - Middle Name:JA
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:7901 BROADWAY
Mailing Address - Street 2:MANAGED CARE, D1-01
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-2490
Mailing Address - Fax:718-334-3432
Practice Address - Street 1:7901 BROADWAY
Practice Address - Street 2:MANAGED CARE, D1-01
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-2490
Practice Address - Fax:718-334-3432
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301430363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00330128Medicare ID - Type Unspecified