Provider Demographics
NPI:1336380203
Name:KIM, SONG JIN SOPHIE (PA)
Entity Type:Individual
Prefix:
First Name:SONG JIN
Middle Name:SOPHIE
Last Name:KIM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13880 BRADDOCK RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2459
Mailing Address - Country:US
Mailing Address - Phone:703-222-2773
Mailing Address - Fax:703-222-6093
Practice Address - Street 1:13880 BRADDOCK RD
Practice Address - Street 2:SUITE 301
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2459
Practice Address - Country:US
Practice Address - Phone:703-222-2773
Practice Address - Fax:703-222-6093
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002960363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant