Provider Demographics
NPI:1215370150
Name:KIM, SOO JUNG (NP)
Entity type:Individual
Prefix:
First Name:SOO JUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 YORK AVENUE
Mailing Address - Street 2:BOX 205
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 EAST 60TH STREET
Practice Address - Street 2:4TH FLOOR, SUITE 404
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022
Practice Address - Country:US
Practice Address - Phone:646-888-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306397363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health