Provider Demographics
NPI:1225894116
Name:LIM, SEOWON
Entity type:Individual
Prefix:
First Name:SEOWON
Middle Name:
Last Name:LIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-1433
Mailing Address - Country:US
Mailing Address - Phone:714-403-1977
Mailing Address - Fax:
Practice Address - Street 1:12506 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-7134
Practice Address - Country:US
Practice Address - Phone:562-809-0142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027817363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily