Provider Demographics
NPI:1285278192
Name:KIM, SANGMIN (APRN)
Entity type:Individual
Prefix:
First Name:SANGMIN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2664 FM 2054
Mailing Address - Street 2:
Mailing Address - City:TENNESSEE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75886-5000
Mailing Address - Country:US
Mailing Address - Phone:903-928-2311
Mailing Address - Fax:
Practice Address - Street 1:2664 FM 2054
Practice Address - Street 2:
Practice Address - City:TENNESSEE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75886-5000
Practice Address - Country:US
Practice Address - Phone:903-928-2311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143489363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty