Healthcare Provider Details

I. General information

NPI: 1487355319
Provider Name (Legal Business Name): JESSE YISU HAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2023
Last Update Date: 09/14/2024
Certification Date: 09/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W CARSON ST
TORRANCE CA
90502-2004
US

IV. Provider business mailing address

1000 W CARSON ST BLDG N18, BOX 461
TORRANCE CA
90502
US

V. Phone/Fax

Practice location:
  • Phone: 714-673-2236
  • Fax:
Mailing address:
  • Phone: 714-673-2236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number15756
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: