Provider Demographics
NPI:1801278908
Name:CHUNG, MIN AE (PA-C)
Entity type:Individual
Prefix:MS
First Name:MIN
Middle Name:AE
Last Name:CHUNG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 S BROOKHURST ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3563
Mailing Address - Country:US
Mailing Address - Phone:949-297-3888
Mailing Address - Fax:
Practice Address - Street 1:631 S BROOKHURST ST STE 101
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3563
Practice Address - Country:US
Practice Address - Phone:949-297-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52562363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical