Provider Demographics
NPI:1962832477
Name:KIM, SAMUEL TAE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:TAE
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 1:3800 SW 34TH ST
Mailing Address - Street 2:APT S174
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-6562
Mailing Address - Country:US
Mailing Address - Phone:407-739-4009
Mailing Address - Fax:
Practice Address - Street 1:1515 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1134
Practice Address - Country:US
Practice Address - Phone:352-733-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107565363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010389300Medicaid
FLHQ819ZMedicare PIN