Healthcare Provider Details

I. General information

NPI: 1003705443
Provider Name (Legal Business Name): CALEB JAESUNG YOO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/01/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 E 72ND ST FL 5
NEW YORK NY
10021-4099
US

IV. Provider business mailing address

5520 LORNA ST
TORRANCE CA
90503-4070
US

V. Phone/Fax

Practice location:
  • Phone: 646-797-8305
  • Fax:
Mailing address:
  • Phone: 310-995-8554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: