Provider Demographics
NPI:1043017569
Name:LY, KIM (PA-C)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:LY
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:12522 SHELLEY DR APT 6
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4940
Mailing Address - Country:US
Mailing Address - Phone:714-837-0386
Mailing Address - Fax:
Practice Address - Street 1:12522 SHELLEY DR APT 6
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4940
Practice Address - Country:US
Practice Address - Phone:714-837-0386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant