Healthcare Provider Details

I. General information

NPI: 1295664282
Provider Name (Legal Business Name): ROSA KIM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHURCH ST S STE A250
NEW HAVEN CT
06519-1703
US

IV. Provider business mailing address

100 CHURCH ST S STE A250
NEW HAVEN CT
06519-1703
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-2860
  • Fax:
Mailing address:
  • Phone: 203-785-2860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13817
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: