Provider Demographics
NPI:1740863828
Name:JEONG, MOONSUN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MOONSUN
Middle Name:
Last Name:JEONG
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3727 W 6TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-5108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3255 WILSHIRE BLVD STE 120
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1405
Practice Address - Country:US
Practice Address - Phone:213-235-2500
Practice Address - Fax:213-355-8714
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95017339363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily