Healthcare Provider Details

I. General information

NPI: 1174260822
Provider Name (Legal Business Name): BIANCA YOUNSEON KANG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2022
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 E MAYO BLVD
PHOENIX AZ
85054-4502
US

IV. Provider business mailing address

5777 E MAYO BLVD
PHOENIX AZ
85054-4502
US

V. Phone/Fax

Practice location:
  • Phone: 480-515-6296
  • Fax: 805-569-8358
Mailing address:
  • Phone: 480-515-6296
  • Fax: 805-569-8358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number69832
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: