Provider Demographics
NPI:1922317486
Name:NGO, KIM (PA-C)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:NGO
Suffix:
Gender:F
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 1:433 N CAMDEN DR FL 6
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4416
Mailing Address - Country:US
Mailing Address - Phone:855-254-1434
Mailing Address - Fax:
Practice Address - Street 1:433 N CAMDEN DR FL 6
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4416
Practice Address - Country:US
Practice Address - Phone:855-254-1434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2020-11-04
Deactivation Date:2020-10-23
Deactivation Code:
Reactivation Date:2020-11-04
Provider Licenses
StateLicense IDTaxonomies
CA21319363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant