Provider Demographics
NPI:1588907802
Name:YIM, JENNIFER SHIN (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SHIN
Last Name:YIM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-5824
Mailing Address - Country:US
Mailing Address - Phone:909-391-4138
Mailing Address - Fax:909-391-4395
Practice Address - Street 1:1650 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-5824
Practice Address - Country:US
Practice Address - Phone:909-391-4138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22803363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22803OtherPHYSICIAN ASSISTANT LICENSE