Healthcare Provider Details

I. General information

NPI: 1033204631
Provider Name (Legal Business Name): YONG KU KWON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: YONG K KWON PA

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5677 BUFORD HWY NE STE 210
DORAVILLE GA
30340-1200
US

IV. Provider business mailing address

5677 BUFORD HWY NE STE 210
DORAVILLE GA
30340-1200
US

V. Phone/Fax

Practice location:
  • Phone: 678-547-1045
  • Fax: 678-547-1048
Mailing address:
  • Phone: 678-547-1045
  • Fax: 678-547-1048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004834
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: