Provider Demographics
NPI:1962894931
Name:SEO, SU JIN
Entity type:Individual
Prefix:
First Name:SU JIN
Middle Name:
Last Name:SEO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13909 28TH RD
Mailing Address - Street 2:APT 6C
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-1848
Mailing Address - Country:US
Mailing Address - Phone:718-216-5455
Mailing Address - Fax:
Practice Address - Street 1:13909 28TH RD
Practice Address - Street 2:APT 6C
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-1848
Practice Address - Country:US
Practice Address - Phone:718-216-5455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307204363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health