Provider Demographics
NPI:1336847797
Name:KIM, NATHAN JUNGWON
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:JUNGWON
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2684 N RIVER TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-2013
Mailing Address - Country:US
Mailing Address - Phone:760-490-7285
Mailing Address - Fax:
Practice Address - Street 1:8327 DAVIS ST STE 202
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4998
Practice Address - Country:US
Practice Address - Phone:562-923-2445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95024170363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics