Healthcare Provider Details

I. General information

NPI: 1659723021
Provider Name (Legal Business Name): WOO JUNG KIM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 FORT WASHINGTON AVE
NEW YORK NY
10032-3729
US

IV. Provider business mailing address

630 W 168TH ST # 4
NEW YORK NY
10032-3725
US

V. Phone/Fax

Practice location:
  • Phone: 212-326-8532
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number019827
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number019827
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: