Healthcare Provider Details

I. General information

NPI: 1306377254
Provider Name (Legal Business Name): MIJUNG SHIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 GRAND CONCOURSE
BRONX NY
10453
US

IV. Provider business mailing address

3198 GRAND CONCOURSE
BRONX NY
10458-1000
US

V. Phone/Fax

Practice location:
  • Phone: 718-299-7295
  • Fax:
Mailing address:
  • Phone: 718-618-0401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberF341131
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF341131
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: