Provider Demographics
NPI:1104547769
Name:KIM, WANSEUNG (APRN)
Entity type:Individual
Prefix:
First Name:WANSEUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:VINCENT WANSEUNG
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:5367 PEACOCK LILY ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-1267
Mailing Address - Country:US
Mailing Address - Phone:702-218-0133
Mailing Address - Fax:
Practice Address - Street 1:6870 S RAINBOW BLVD STE 107
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-2107
Practice Address - Country:US
Practice Address - Phone:702-750-0659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN67339163W00000X
NV856178363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse