Provider Demographics
NPI:1639343767
Name:KO, YOUNG S (MSOM, LAC)
Entity type:Individual
Prefix:
First Name:YOUNG
Middle Name:S
Last Name:KO
Suffix:
Gender:F
Credentials:MSOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 2ND ST APT 1510
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-3080
Mailing Address - Country:US
Mailing Address - Phone:201-687-6659
Mailing Address - Fax:
Practice Address - Street 1:20 2ND ST APT 1510
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-3080
Practice Address - Country:US
Practice Address - Phone:201-687-6659
Practice Address - Fax:201-256-3739
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMZ00047100171100000X
NY003180-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist