Provider Demographics
NPI:1851840763
Name:KWON, JI MIN (MPAP, PA-C)
Entity Type:Individual
Prefix:
First Name:JI MIN
Middle Name:
Last Name:KWON
Suffix:
Gender:F
Credentials:MPAP, PA-C
Other - Prefix:
Other - First Name:JI MIN
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5155 DOVER DR
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-2312
Mailing Address - Country:US
Mailing Address - Phone:562-279-5876
Mailing Address - Fax:
Practice Address - Street 1:7281 BOURBON LN
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1104
Practice Address - Country:US
Practice Address - Phone:562-279-5876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53638363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant