Provider Demographics
NPI:1720514466
Name:GO, KYUNGSOO KORINN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KYUNGSOO
Middle Name:KORINN
Last Name:GO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KYUNGSOO
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8891 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1618
Mailing Address - Country:US
Mailing Address - Phone:909-297-3361
Mailing Address - Fax:
Practice Address - Street 1:8891 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-1618
Practice Address - Country:US
Practice Address - Phone:909-297-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant