Provider Demographics
NPI:1386333151
Name:KIM, MIDEUM TIMOTHY (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MIDEUM
Middle Name:TIMOTHY
Last Name:KIM
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2776 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2613
Mailing Address - Country:US
Mailing Address - Phone:562-997-2049
Mailing Address - Fax:562-595-6985
Practice Address - Street 1:2776 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2613
Practice Address - Country:US
Practice Address - Phone:562-997-2049
Practice Address - Fax:562-595-6985
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95024886363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily