Provider Demographics
NPI:1770298218
Name:KIM, JAE KYUN
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:KYUN
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 E 63RD ST APT 11F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7934
Mailing Address - Country:US
Mailing Address - Phone:646-942-2510
Mailing Address - Fax:
Practice Address - Street 1:450 E 63RD ST APT 11F
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-7934
Practice Address - Country:US
Practice Address - Phone:646-942-2510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY556136-01163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical