Provider Demographics
NPI:1013513811
Name:KIM, DANIEL E (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:E
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 1:284 E HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3706
Mailing Address - Country:US
Mailing Address - Phone:909-883-1098
Mailing Address - Fax:909-883-0653
Practice Address - Street 1:284 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3706
Practice Address - Country:US
Practice Address - Phone:909-883-1098
Practice Address - Fax:909-883-0653
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant