Healthcare Provider Details

I. General information

NPI: 1104766526
Provider Name (Legal Business Name): NAYOUNG KWAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 BARTON ST
BUFFALO NY
14213-1573
US

IV. Provider business mailing address

916 DELAWARE AVE APT 5C
BUFFALO NY
14209-1851
US

V. Phone/Fax

Practice location:
  • Phone: 716-881-6191
  • Fax:
Mailing address:
  • Phone: 405-615-5597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1104766526
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: