Provider Demographics
NPI:1275368409
Name:FISHMAN, JI SOO CHUNG (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:JI SOO
Middle Name:CHUNG
Last Name:FISHMAN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 REVERE ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-1633
Mailing Address - Country:US
Mailing Address - Phone:915-564-6100
Mailing Address - Fax:
Practice Address - Street 1:350 REVERE ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-1633
Practice Address - Country:US
Practice Address - Phone:915-564-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1029254163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health