Provider Demographics
NPI:1952447625
Name:KIM, JIN TAEK (JIN KIM PA-C)
Entity Type:Individual
Prefix:MR
First Name:JIN
Middle Name:TAEK
Last Name:KIM
Suffix:
Gender:M
Credentials:JIN KIM PA-C
Other - Prefix:MR
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:25 MIWOK WAY
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2593
Mailing Address - Country:US
Mailing Address - Phone:415-383-0917
Mailing Address - Fax:
Practice Address - Street 1:400 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2202
Practice Address - Country:US
Practice Address - Phone:415-353-2954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18112363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical