Healthcare Provider Details

I. General information

NPI: 1124687884
Provider Name (Legal Business Name): KIA YANG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 491 NORTH
SHIPROCK NM
87420
US

IV. Provider business mailing address

1136 ALBEMARLE ST
SAINT PAUL MN
55117-4415
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6001
  • Fax: 505-368-7411
Mailing address:
  • Phone: 505-368-6001
  • Fax: 505-368-7411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3643
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: