Basic Information
| Provider Information | |||||||||
| NPI: | 1366927741 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANG | ||||||||
| FirstName: | SONG | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3727 N NORTHHAVEN CT APT 2A | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625269250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182019860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 320 E CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625214665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178774694 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2018 | ||||||||
| LastUpdateDate: | 10/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 085006761 | IL | N | Allopathic & Osteopathic Physicians | General Practice | 363AM0700X | 085006761 | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.