=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912783267
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUN KYUNG KIM PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2023
-----------------------------------------------------
Last Update Date | 05/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 TELESTAR CT # 501
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22042-1260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-946-7746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14811 RETREAT BLVD
-----------------------------------------------------
City | CHANTILLY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20151-3999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-975-3226
-----------------------------------------------------
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 | 0110009482
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------