Provider Demographics
NPI:1922035948
Name:KIM, DAVID Y (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:Y
Last Name:KIM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-5047
Mailing Address - Country:US
Mailing Address - Phone:626-857-2580
Mailing Address - Fax:
Practice Address - Street 1:1365 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-5047
Practice Address - Country:US
Practice Address - Phone:626-857-2580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ44428Medicare UPIN
CAWPA17440FMedicare PIN
CAWPA17440GMedicare PIN