Provider Demographics
NPI:1477707453
Name:KIM, GINA B (PA-C)
Entity type:Individual
Prefix:MISS
First Name:GINA
Middle Name:B
Last Name:KIM
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 1:176 S SHADOW PINES RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-6566
Mailing Address - Country:US
Mailing Address - Phone:310-909-4717
Mailing Address - Fax:
Practice Address - Street 1:3828 DELMAS TER
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2713
Practice Address - Country:US
Practice Address - Phone:310-909-4717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19968363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical