Provider Demographics
NPI:1710401484
Name:KWON, BOGUM (PA)
Entity type:Individual
Prefix:
First Name:BOGUM
Middle Name:
Last Name:KWON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 NORTHERN BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5322
Mailing Address - Country:US
Mailing Address - Phone:516-498-8400
Mailing Address - Fax:
Practice Address - Street 1:833 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5315
Practice Address - Country:US
Practice Address - Phone:516-498-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AS0400X
NY021238363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical