Provider Demographics
NPI:1275371387
Name:JANG, GEUNHYUCK
Entity type:Individual
Prefix:
First Name:GEUNHYUCK
Middle Name:
Last Name:JANG
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 1:1821 E COVINA ST APT 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-7526
Mailing Address - Country:US
Mailing Address - Phone:951-207-2547
Mailing Address - Fax:
Practice Address - Street 1:1331 N 7TH ST STE 375
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2707
Practice Address - Country:US
Practice Address - Phone:602-307-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1275371387363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty