=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821506775
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOHYUN LIM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2018
-----------------------------------------------------
Last Update Date | 09/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18773 COLIMA RD
-----------------------------------------------------
City | ROWLAND HEIGHTS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-986-4899
-----------------------------------------------------
Fax | 626-986-4855
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6084 ORANGE AVE
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90630-3329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-415-4628
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA55246
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 55246
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------