Basic Information
| Provider Information | |||||||||
| NPI: | 1699382978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | YOUNG | ||||||||
| MiddleName: | RON | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 W JOHN CARPENTER FWY STE 420 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750392014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729573000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1306 TEASLEY LN | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762057946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403825005 | ||||||||
| FaxNumber: | 9403825803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2020 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1017712 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.