Provider Demographics
NPI:1265951412
Name:KIM, MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:YI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 PARK AVE APT 330
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-4778
Mailing Address - Country:US
Mailing Address - Phone:443-878-8550
Mailing Address - Fax:
Practice Address - Street 1:3333 N CALVERT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2867
Practice Address - Country:US
Practice Address - Phone:410-554-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant