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General NPI Number Information
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NPI Number | 1477017275
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Entity Type | Individual
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Provider Name | JAE ROCK SHIM CRNA
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Gender | Male
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Dates
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Enumeration Date | 01/25/2019
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Last Update Date | 08/02/2022
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Provider Practice Location Address
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Address Line | 1300 N VERMONT AVE
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City | LOS ANGELES
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State | CA
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Zip | 90027-6098
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Country | US
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Telephone | 213-413-3000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 25033
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City | SANTA ANA
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State | CA
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Zip | 92799-5033
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Country | US
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Telephone | 714-347-1000
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Fax | 714-347-1082
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN686691
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 209.018963
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 95001105
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License Number State | CA
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