Basic Information
| Provider Information | |||||||||
| NPI: | 1588049837 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | HWAYEON | ||||||||
| MiddleName: | STELLA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHON | ||||||||
| OtherFirstName: | JUHYANG (STELLA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 161 RIVERSIDE DR STE 306 | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139054197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077986700 | ||||||||
| FaxNumber: | 6077986745 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 RIVERSIDE DR STE 306 | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139054197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077986700 | ||||||||
| FaxNumber: | 6077986745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2015 | ||||||||
| LastUpdateDate: | 12/08/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 339747 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.