Provider Demographics
NPI:1871821587
Name:PAK, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:PAK
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 1:136-20 38 AVE
Mailing Address - Street 2:SUITE 6F
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4263
Mailing Address - Country:US
Mailing Address - Phone:718-888-9700
Mailing Address - Fax:718-888-9796
Practice Address - Street 1:136-20 38TH AVE
Practice Address - Street 2:SUITE 6F
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4263
Practice Address - Country:US
Practice Address - Phone:718-888-9700
Practice Address - Fax:718-888-9796
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013681-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant