Provider Demographics
NPI:1972020824
Name:KIM, HAESOOK (NP)
Entity Type:Individual
Prefix:MRS
First Name:HAESOOK
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 YGNACIO VALLEY RD STE K200
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3336
Mailing Address - Country:US
Mailing Address - Phone:925-926-0195
Mailing Address - Fax:925-926-0194
Practice Address - Street 1:2123 YGNACIO VALLEY RD STE K200
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3336
Practice Address - Country:US
Practice Address - Phone:925-926-0195
Practice Address - Fax:925-926-0194
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004733363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner