Healthcare Provider Details

I. General information

NPI: 1245986140
Provider Name (Legal Business Name): KYUNGMOON ROH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 09/28/2024
Certification Date: 09/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

575 LEXINGTON AVE
NEW YORK NY
10022-6102
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2419
  • Fax:
Mailing address:
  • Phone: 646-413-9909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NJ01262000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number680524
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: