Provider Demographics
NPI:1447683073
Name:KIM, KI S (NP)
Entity type:Individual
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First Name:KI
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:NP
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Mailing Address - Street 1:2901 TELESTAR CT STE 300
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1263
Mailing Address - Country:US
Mailing Address - Phone:703-591-1688
Mailing Address - Fax:703-591-1445
Practice Address - Street 1:1900 GALLOWS RD STE 110
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-4098
Practice Address - Country:US
Practice Address - Phone:703-281-1265
Practice Address - Fax:703-255-0571
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2024-08-23
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Provider Licenses
StateLicense IDTaxonomies
VA0024171030363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1447683073Medicaid