Provider Demographics
NPI:1790489102
Name:KIM, NOAH EUISUB
Entity Type:Individual
Prefix:
First Name:NOAH
Middle Name:EUISUB
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 1:4309 W MEDICAL CENTER DR STE B202
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8417
Mailing Address - Country:US
Mailing Address - Phone:815-455-2752
Mailing Address - Fax:815-455-2789
Practice Address - Street 1:4309 W MEDICAL CENTER DR STE B202
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8417
Practice Address - Country:US
Practice Address - Phone:815-455-2752
Practice Address - Fax:815-455-2789
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IL085009901363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant