Provider Demographics
NPI:1083258610
Name:KIM, DA HUN
Entity type:Individual
Prefix:
First Name:DA HUN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:7503 SURRATTS RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3358
Mailing Address - Country:US
Mailing Address - Phone:352-361-5116
Mailing Address - Fax:
Practice Address - Street 1:7503 SURRATTS RD STE 208
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3358
Practice Address - Country:US
Practice Address - Phone:301-877-4367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2024-06-26
Deactivation Date:2024-05-15
Deactivation Code:
Reactivation Date:2024-06-03
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MD363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician