Healthcare Provider Details

I. General information

NPI: 1386065092
Provider Name (Legal Business Name): JI EUN KIM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GENIE KIM PA-C

II. Dates (important events)

Enumeration Date: 12/23/2013
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SAN PABLO ST FL 4
LOS ANGELES CA
90033-5313
US

IV. Provider business mailing address

PO BOX 50938
LOS ANGELES CA
90074-0938
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-7400
  • Fax:
Mailing address:
  • Phone: 323-442-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA056549
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9107704
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13716
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67248
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3934
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: