Basic Information
| Provider Information | |||||||||
| NPI: | 1326533266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JUNG | ||||||||
| FirstName: | MOON | ||||||||
| MiddleName: | YOUNG | ||||||||
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| Credential: | CAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2619 GADSEN WALK | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300974351 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702773056 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2018 | ||||||||
| LastUpdateDate: | 11/15/2018 | ||||||||
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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 | 367H00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | 9002 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.