MEDICARE: BORA KWON APN-CNP

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	363L00000X	Nurse Practitioner	209033178	IL
2	363LF0000X	Family Nurse Practitioner	209033178	IL

General Provider Information

NPI Number	:	1992670368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BORA KWON APN-CNP

Provider Business Mailing Address
First Line	:	2650 RIDGE AVE
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1700
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5140 N CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3645
Country	:	US
Telephone Number	:	773-989-3957
Fax Number	:

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

Provider Enumeration Date	:	10/07/2025
Last Update Date	:	04/09/2026

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