Provider Demographics
NPI:1811513005
Name:KIM, CONSTANCE H (PA-C)
Entity type:Individual
Prefix:MISS
First Name:CONSTANCE
Middle Name:H
Last Name:KIM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:CONSTANCE
Other - Middle Name:H
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:232 MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2623
Mailing Address - Country:US
Mailing Address - Phone:516-594-5961
Mailing Address - Fax:516-256-5556
Practice Address - Street 1:3096 51ST ST
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-1457
Practice Address - Country:US
Practice Address - Phone:718-204-1469
Practice Address - Fax:718-545-1726
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant