=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255903217
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HYUN JOO NAM CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2021
-----------------------------------------------------
Last Update Date | 08/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PO BOX 22410
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93390-2410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-419-8769
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 NEW HVN
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92620-3285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | 323008
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 7277
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------