=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770952640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUNG SUNG CHOI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2015
-----------------------------------------------------
Last Update Date | 09/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4723 213TH ST # 1STFL
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-3327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-460-5095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4723 213TH ST # 1STFL
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-3327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-460-5095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 019045
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------