Provider Demographics
NPI:1750869491
Name:JIN, JINSHAN
Entity type:Individual
Prefix:
First Name:JINSHAN
Middle Name:
Last Name:JIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 GENESEE STREET
Mailing Address - Street 2:BUSINESS OFFICE ROOM 310
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5930
Mailing Address - Country:US
Mailing Address - Phone:315-801-3282
Mailing Address - Fax:
Practice Address - Street 1:1903 SUNSET AVE # 3
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5617
Practice Address - Country:US
Practice Address - Phone:315-797-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022394363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical