Healthcare Provider Details

I. General information

NPI: 1306708243
Provider Name (Legal Business Name): HYUNSUN JO AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 11/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 PONDSIDE CT
HARRINGTON PARK NJ
07640-1057
US

IV. Provider business mailing address

18 PONDSIDE CT
HARRINGTON PARK NJ
07640-1057
US

V. Phone/Fax

Practice location:
  • Phone: 917-485-2664
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF312543
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: