Healthcare Provider Details

I. General information

NPI: 1750920559
Provider Name (Legal Business Name): YOUNG SOON KEUM FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2019
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 PYRAMID WAY STE 206
SPARKS NV
89431-4470
US

IV. Provider business mailing address

PO BOX 16793
SOUTH LAKE TAHOE CA
96151-6793
US

V. Phone/Fax

Practice location:
  • Phone: 775-710-8380
  • Fax: 949-543-2069
Mailing address:
  • Phone: 530-545-8782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number832549
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: