Provider Demographics
NPI:1962877282
Name:NICKERSON, GASONG YUN
Entity type:Individual
Prefix:
First Name:GASONG
Middle Name:YUN
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOO YEON
Other - Middle Name:
Other - Last Name:YUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2800 L ST STE 500
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5616
Mailing Address - Country:US
Mailing Address - Phone:916-454-6850
Mailing Address - Fax:
Practice Address - Street 1:2800 L ST STE 500
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5616
Practice Address - Country:US
Practice Address - Phone:916-454-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340096363LF0000X
CA95004720363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily