Basic Information
| Provider Information | |||||||||
| NPI: | 1205141637 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | MYUNG | ||||||||
| MiddleName: | KANG | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 2546 BALLTOWN RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123091079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183741444 | ||||||||
| FaxNumber: | 5183740491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2010 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F336412 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | F336410 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 03274953 | 05 | NY | MEDICAID |