MEDICARE: MR. JAE HWAN CHUNG NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95004056	CA

General Provider Information

NPI Number	:	1184053662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAE HWAN CHUNG NP

Provider Business Mailing Address
First Line	:	1720 MISSION ST APT 5
Second Line	:
City	:	SOUTH PASADENA
State	:	CA
Zip	:	91030-3329
Country	:	US
Telephone Number	:	310-850-9925
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 S VIRGIL AVE STE 507
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-1452
Country	:	US
Telephone Number	:	310-850-9925
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2013
Last Update Date	:	06/16/2016

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