Provider Demographics
NPI:1235594185
Name:SUNG, EUNJAE (CRNP)
Entity type:Individual
Prefix:
First Name:EUNJAE
Middle Name:
Last Name:SUNG
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 W GARDENA BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4764
Mailing Address - Country:US
Mailing Address - Phone:716-480-4363
Mailing Address - Fax:
Practice Address - Street 1:1740 W GARDENA BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4764
Practice Address - Country:US
Practice Address - Phone:164-804-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-18
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174203208M00000X
MDR218810363LA2200X
CA95010489363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health