MEDICARE: KELLY KIM

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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1366309080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY KIM

Provider Business Mailing Address
First Line	:	760 BROADWAY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11206-5317
Country	:	US
Telephone Number	:	718-963-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	760 BROADWAY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11206-5317
Country	:	US
Telephone Number	:	718-963-8000
Fax Number	:

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

Provider Enumeration Date	:	01/06/2026
Last Update Date	:	01/06/2026

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Directions to “ KELLY KIM ” Practice Location

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