Basic Information
| Provider Information | |||||||||
| NPI: | 1265633077 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | JUNE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4230 BURNHAM AVE | ||||||||
| Address2: | ASSOCIATED PATHOLOGISTS, CHARTERED | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891195408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027337866 | ||||||||
| FaxNumber: | 7027921319 | ||||||||
| Practice Location | |||||||||
| Address1: | 4230 BURNHAM AVE | ||||||||
| Address2: | ASSOCIATED PATHOLOGISTS, CHARTERED | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891195408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027337866 | ||||||||
| FaxNumber: | 7027921319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 10/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | A108582 | CA | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZC0500X | 12851 | NV | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | MD430805 | PA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | A108582 | CA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 12851 | NV | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 12851 | 01 | NV | MEDICAL LICENSE | OTHER | 1265633077 | 05 | NV | MEDICAID | A108582 | 01 | CA | MEDICAL LICENSE | OTHER |