Provider Demographics
NPI:1972062529
Name:JI, HYEONG JUN (ATC)
Entity Type:Individual
Prefix:
First Name:HYEONG JUN
Middle Name:
Last Name:JI
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:PETER
Other - Middle Name:
Other - Last Name:JI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC
Mailing Address - Street 1:5160 VAN KLEECK ST APT 6N
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4216
Mailing Address - Country:US
Mailing Address - Phone:646-943-0027
Mailing Address - Fax:
Practice Address - Street 1:1 REDMEN ST
Practice Address - Street 2:
Practice Address - City:ISLIP TERRACE
Practice Address - State:NY
Practice Address - Zip Code:11752-2805
Practice Address - Country:US
Practice Address - Phone:646-943-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003710-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer