Healthcare Provider Details

I. General information

NPI: 1588907802
Provider Name (Legal Business Name): JENNIFER SHIN YIM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 S EUCLID AVE
ONTARIO CA
91762-5824
US

IV. Provider business mailing address

1650 S EUCLID AVE
ONTARIO CA
91762-5824
US

V. Phone/Fax

Practice location:
  • Phone: 909-391-4138
  • Fax:
Mailing address:
  • Phone: 909-391-4138
  • Fax: 909-391-4395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA22803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: