Healthcare Provider Details

I. General information

NPI: 1528721586
Provider Name (Legal Business Name): EVA KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 BROADWAY
LONG ISLAND CITY NY
11106-4530
US

IV. Provider business mailing address

1430 BROADWAY
LONG ISLAND CITY NY
11106-4530
US

V. Phone/Fax

Practice location:
  • Phone: 929-656-3407
  • Fax:
Mailing address:
  • Phone: 929-656-3407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number383506
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number26NJ01217100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: