Basic Information
| Provider Information | |||||||||
| NPI: | 1881083103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | YOO | ||||||||
| MiddleName: | JUNG | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1825 THISTLE HILL DR | ||||||||
| Address2: | APT 17101 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761107434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172393151 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5323 HARRY HINES BLVD | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753907201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146483111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2015 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 817179 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.