Basic Information
| Provider Information | |||||||||
| NPI: | 1881641892 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIN | ||||||||
| FirstName: | SOOK-JA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1510 EL NITA LN | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925444603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519296260 | ||||||||
| FaxNumber: | 9517652855 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924111217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098876333 | ||||||||
| FaxNumber: | 9098061017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 04/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A37091 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A370910 | 05 | CA | MEDICAID |