1205180981 NPI number — CHRISTINA CHAN KIM PA-C

Table of content: CHRISTINA CHAN KIM PA-C (NPI 1205180981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205180981 NPI number — CHRISTINA CHAN KIM PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
CHRISTINA
Provider Middle Name:
CHAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205180981
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2282 CLARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FULLERTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92833-5616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-323-2132
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9449 IMPERIAL HWY
Provider Second Line Business Practice Location Address:
BUILDING A, SUITE 309
Provider Business Practice Location Address City Name:
DOWNEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90242-2814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-657-2483
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA22672 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA22672 . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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