Healthcare Provider Details

I. General information

NPI: 1306846399
Provider Name (Legal Business Name): KYONG MIN YI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2005
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 G ST
SPRINGFIELD OR
97477-4112
US

IV. Provider business mailing address

PO BOX 3379
TRUCKEE CA
96160-3379
US

V. Phone/Fax

Practice location:
  • Phone: 541-726-4406
  • Fax:
Mailing address:
  • Phone: 408-228-2357
  • Fax: 408-993-8555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD189845
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number18168
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG85233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: