Provider Demographics
NPI:1386132652
Name:KIM, DAE WOONG
Entity type:Individual
Prefix:
First Name:DAE WOONG
Middle Name:
Last Name:KIM
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 1:21321 E OCOTILLO RD STE 133
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-5995
Mailing Address - Country:US
Mailing Address - Phone:480-987-5525
Mailing Address - Fax:480-987-5115
Practice Address - Street 1:21321 E OCOTILLO RD STE 133
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-5995
Practice Address - Country:US
Practice Address - Phone:480-987-5525
Practice Address - Fax:480-987-5115
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant