Provider Demographics
NPI:1457977944
Name:YOO, JIYEAN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:JIYEAN
Middle Name:
Last Name:YOO
Suffix:
Gender:F
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 1:2929 WALNUT ST APT 4424
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5096
Mailing Address - Country:US
Mailing Address - Phone:619-371-0588
Mailing Address - Fax:
Practice Address - Street 1:605 W 42ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-2010
Practice Address - Country:US
Practice Address - Phone:267-951-3799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061470363A00000X
NY026506-01363A00000X
PAOA005209363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant