Healthcare Provider Details

I. General information

NPI: 1386333151
Provider Name (Legal Business Name): MIDEUM TIMOTHY KIM NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2776 PACIFIC AVE
LONG BEACH CA
90806-2613
US

IV. Provider business mailing address

2776 PACIFIC AVE
LONG BEACH CA
90806-2613
US

V. Phone/Fax

Practice location:
  • Phone: 562-997-2049
  • Fax: 562-595-6985
Mailing address:
  • Phone: 562-997-2049
  • Fax: 562-595-6985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95024886
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: