Provider Demographics
NPI:1245751775
Name:KIM, TAEHO (PA)
Entity type:Individual
Prefix:
First Name:TAEHO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:TAE
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1808 SAN MIGUEL DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-8606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1808 SAN MIGUEL DR
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-8606
Practice Address - Country:US
Practice Address - Phone:925-528-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant