Basic Information
Provider Information | |||||||||
NPI: | 1932578739 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | UM | ||||||||
FirstName: | SUNG-MIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2100 POWELL ST STE 900 | ||||||||
Address2: |   | ||||||||
City: | EMERYVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 946081844 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5103502600 | ||||||||
FaxNumber: | 5108799086 | ||||||||
Practice Location | |||||||||
Address1: | 1633 S COURT ST | ||||||||
Address2: |   | ||||||||
City: | VISALIA | ||||||||
State: | CA | ||||||||
PostalCode: | 932774945 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5596246090 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2015 | ||||||||
LastUpdateDate: | 09/22/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 52827 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1121360 | 01 |   | NCCPA | OTHER | 52827 | 01 | CA | CALIFORNIA PHYSICIAN ASSISTANT BOARD | OTHER |