Healthcare Provider Details

I. General information

NPI: 1265633077
Provider Name (Legal Business Name): STACY JUNE KIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 10/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 BURNHAM AVE ASSOCIATED PATHOLOGISTS, CHARTERED
LAS VEGAS NV
89119-5408
US

IV. Provider business mailing address

4230 BURNHAM AVE ASSOCIATED PATHOLOGISTS, CHARTERED
LAS VEGAS NV
89119-5408
US

V. Phone/Fax

Practice location:
  • Phone: 702-733-7866
  • Fax: 702-792-1319
Mailing address:
  • Phone: 702-733-7866
  • Fax: 702-792-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberA108582
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number12851
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD430805
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA108582
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number12851
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: