Basic Information
| Provider Information | |||||||||
| NPI: | 1295065308 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JU HYUNG | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12125 WOODCREST EXECUTIVE DR | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631415001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143170600 | ||||||||
| FaxNumber: | 3143170606 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 1ST CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633012844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143170600 | ||||||||
| FaxNumber: | 3143170606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2010 | ||||||||
| LastUpdateDate: | 05/08/2012 | ||||||||
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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 | 2006021680 | MO | N | Nursing Service Providers | Registered Nurse | 363L00000X | 2006021680 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1295065308 | 05 | MO | MEDICAID |