Provider Demographics
NPI:1780394361
Name:KIM, HYESUK
Entity type:Individual
Prefix:
First Name:HYESUK
Middle Name:
Last Name:KIM
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 1:1662 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:COLONIE
Mailing Address - State:NY
Mailing Address - Zip Code:12205-4059
Mailing Address - Country:US
Mailing Address - Phone:518-240-1456
Mailing Address - Fax:
Practice Address - Street 1:1662 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COLONIE
Practice Address - State:NY
Practice Address - Zip Code:12205-4059
Practice Address - Country:US
Practice Address - Phone:518-240-1456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF350030363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner