MEDICARE: DAVID SHIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1366112526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID SHIN

Provider Business Mailing Address
First Line	:	2175 LEMOINE AVE FL 6
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-6008
Country	:	US
Telephone Number	:	201-886-9000
Fax Number	:	718-961-0666

Provider Business Practice Location Address
First Line	:	2175 LEMOINE AVE FL 6
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-6008
Country	:	US
Telephone Number	:	866-722-3338
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2021
Last Update Date	:	01/26/2022

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Directions to “ DAVID SHIN ” Practice Location

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