Provider Demographics
NPI:1023524956
Name:HAN, KYONG SU (LAC)
Entity type:Individual
Prefix:
First Name:KYONG SU
Middle Name:
Last Name:HAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2449B ROSSETT ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-3919
Mailing Address - Country:US
Mailing Address - Phone:201-240-2488
Mailing Address - Fax:
Practice Address - Street 1:100 ROUTE 303
Practice Address - Street 2:
Practice Address - City:TAPPAN
Practice Address - State:NY
Practice Address - Zip Code:10983-2117
Practice Address - Country:US
Practice Address - Phone:845-680-6294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025130-1225700000X
NY006038-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty