Provider Demographics
NPI:1427349869
Name:KWON, NICOLE BOON JUNG (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:BOON JUNG
Last Name:KWON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BOON JUNG
Other - Middle Name:
Other - Last Name:KWON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:34 MARK WEST SPRINGS ROAD
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403
Mailing Address - Country:US
Mailing Address - Phone:707-541-7900
Mailing Address - Fax:707-573-5413
Practice Address - Street 1:34 MARK WEST SPRINGS ROAD
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403
Practice Address - Country:US
Practice Address - Phone:707-541-7900
Practice Address - Fax:707-573-5413
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA124134207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology