Basic Information
| Provider Information | |||||||||
| NPI: | 1912492216 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KWON | ||||||||
| FirstName: | JI | ||||||||
| MiddleName: | YEON | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL # GE07 | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936368762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593536277 | ||||||||
| FaxNumber: | 5593537195 | ||||||||
| Practice Location | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL # GE07 | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593536277 | ||||||||
| FaxNumber: | 5593537195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2018 | ||||||||
| LastUpdateDate: | 07/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 821931 | CA | N | Nursing Service Providers | Registered Nurse | 363L00000X | 95009482 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.