Provider Demographics
NPI:1700258837
Name:KIM, GEON (CRNA)
Entity Type:Individual
Prefix:
First Name:GEON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 E OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-7092
Mailing Address - Country:US
Mailing Address - Phone:805-737-3300
Mailing Address - Fax:
Practice Address - Street 1:1515 E OCEAN AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7092
Practice Address - Country:US
Practice Address - Phone:805-737-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY726346367500000X
CA95000371367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered