Provider Demographics
NPI:1063771202
Name:KIM, EUI
Entity type:Individual
Prefix:
First Name:EUI
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EUI
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:466 OLD HOOK RD STE 1
Mailing Address - Street 2:
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1368
Mailing Address - Country:US
Mailing Address - Phone:201-967-8221
Mailing Address - Fax:
Practice Address - Street 1:466 OLD HOOK RD STE 1
Practice Address - Street 2:
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1368
Practice Address - Country:US
Practice Address - Phone:201-967-8221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337269363LF0000X
NJ26NJ00788400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily