Basic Information
| Provider Information | |||||||||
| NPI: | 1841285152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONG | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | HYEJUNG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHIM | ||||||||
| OtherFirstName: | DIANA | ||||||||
| OtherMiddleName: | HYEJUNG | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 222 STATION PLZ N | ||||||||
| Address2: | SUITE 611 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166632532 | ||||||||
| FaxNumber: | 5166632233 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MINEOLA BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166634600 | ||||||||
| FaxNumber: | 5166633826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | F381261 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02160089 | 05 | NY | MEDICAID |