Provider Demographics
NPI:1134801756
Name:HYUN, JIWOONG (PA-C)
Entity type:Individual
Prefix:
First Name:JIWOONG
Middle Name:
Last Name:HYUN
Suffix:
Gender:
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 1:28741 HERBERT ST
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2908
Mailing Address - Country:US
Mailing Address - Phone:248-761-7155
Mailing Address - Fax:
Practice Address - Street 1:17177 N LAUREL PARK DR STE 131
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3952
Practice Address - Country:US
Practice Address - Phone:734-462-3210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011944363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant