Provider Demographics
NPI:1720116163
Name:KIM, HYO JIN (NP)
Entity type:Individual
Prefix:MS
First Name:HYO
Middle Name:JIN
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1357 HEMBREE ROAD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5723
Mailing Address - Country:US
Mailing Address - Phone:770-664-6075
Mailing Address - Fax:770-664-5131
Practice Address - Street 1:1357 HEMBREE ROAD
Practice Address - Street 2:SUITE 150
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5723
Practice Address - Country:US
Practice Address - Phone:770-664-6075
Practice Address - Fax:770-664-5131
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA118947363L00000X
GARN118947NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112614AMedicaid
GAQ25179Medicare UPIN
GA202I505627Medicare PIN