Basic Information
| Provider Information | |||||||||
| NPI: | 1437789195 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KWON | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | KEN | ||||||||
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| Credential: | PA-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4171 PASEO DE PLATA | ||||||||
| Address2: | |||||||||
| City: | CYPRESS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906303428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146141600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 S SUNSET AVE | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917903940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269624011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2020 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA57831 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.