Provider Demographics
NPI:1942388061
Name:KIM, JIYON JENNIFER (PA-C, MPAS)
Entity Type:Individual
Prefix:
First Name:JIYON
Middle Name:JENNIFER
Last Name:KIM
Suffix:
Gender:F
Credentials:PA-C, MPAS
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Mailing Address - Street 1:755 PARK AVE
Mailing Address - Street 2:STE 500
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3979
Mailing Address - Country:US
Mailing Address - Phone:631-271-2769
Mailing Address - Fax:631-271-1730
Practice Address - Street 1:727 BROADWAY
Practice Address - Street 2:SUITE B4
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758
Practice Address - Country:US
Practice Address - Phone:516-799-0210
Practice Address - Fax:516-799-6569
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2019-05-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY006956363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400020059Medicare PIN
NYS69578Medicare UPIN