Basic Information
| Provider Information | |||||||||
| NPI: | 1811539679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KIM | ||||||||
| OtherFirstName: | MIN SUE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 35380 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891335380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028775199 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7061 GRAND MONTECITO PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891490287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028775199 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2019 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2224 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.