Provider Demographics
NPI:1063257178
Name:KIM, SOYOUNG
Entity type:Individual
Prefix:
First Name:SOYOUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 CROPWELL LN
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:PA
Mailing Address - Zip Code:18966-2585
Mailing Address - Country:US
Mailing Address - Phone:267-978-4290
Mailing Address - Fax:
Practice Address - Street 1:1626 LOCUST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-6305
Practice Address - Country:US
Practice Address - Phone:267-978-4290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP029814363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health