Provider Demographics
NPI:1841697513
Name:KIM, MIN KYUNG (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MIN
Middle Name:KYUNG
Last Name:KIM
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 1:8876 MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92509-2811
Mailing Address - Country:US
Mailing Address - Phone:951-360-8795
Mailing Address - Fax:
Practice Address - Street 1:8876 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:JURUPA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92509-2811
Practice Address - Country:US
Practice Address - Phone:951-360-8795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant