Provider Demographics
NPI:1790035004
Name:KANG, MOONWHA (NP)
Entity Type:Individual
Prefix:
First Name:MOONWHA
Middle Name:
Last Name:KANG
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 1:845 PALMER AVE DEPT OF
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-2406
Mailing Address - Country:US
Mailing Address - Phone:914-864-5857
Mailing Address - Fax:914-864-5859
Practice Address - Street 1:845 PALMER AVE DEPT OF
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543
Practice Address - Country:US
Practice Address - Phone:914-864-5857
Practice Address - Fax:914-864-5859
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305931363LA2200X
NYF340829363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400150755OtherMEDICARE
NY03574701Medicaid