Provider Demographics
NPI:1891372421
Name:KIM, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:KIM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 N TENAYA WAY
Mailing Address - Street 2:GRADUATE MEDICAL EDUCATION
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 N TENAYA WAY
Practice Address - Street 2:GRADUATE MEDICAL EDUCATION
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128
Practice Address - Country:US
Practice Address - Phone:702-962-9540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-28
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO3758207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV433965300Medicaid