Provider Demographics
NPI:1154800902
Name:KANG, JIWON
Entity type:Individual
Prefix:
First Name:JIWON
Middle Name:
Last Name:KANG
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 1:37-59 61 STREET
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2591
Mailing Address - Country:US
Mailing Address - Phone:646-239-6072
Mailing Address - Fax:
Practice Address - Street 1:4277 65TH PL
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-5054
Practice Address - Country:US
Practice Address - Phone:646-239-6072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist