Provider Demographics
NPI:1457236689
Name:KIM, MIRA
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16358 CAMEO CT
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90604-4031
Mailing Address - Country:US
Mailing Address - Phone:714-353-6339
Mailing Address - Fax:
Practice Address - Street 1:2888 LONG BEACH BLVD STE 340
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1552
Practice Address - Country:US
Practice Address - Phone:562-933-0590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95034754363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health