Provider Demographics
NPI:1902267461
Name:KANG, KU IN
Entity Type:Individual
Prefix:
First Name:KU IN
Middle Name:
Last Name:KANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 SOUTH ROUTE 4
Mailing Address - Street 2:207
Mailing Address - City:HAGATNA
Mailing Address - State:GU
Mailing Address - Zip Code:96932
Mailing Address - Country:US
Mailing Address - Phone:671-477-2873
Mailing Address - Fax:
Practice Address - Street 1:302 SOUTH ROUTE 4
Practice Address - Street 2:207
Practice Address - City:HAGATNA
Practice Address - State:GU
Practice Address - Zip Code:96932
Practice Address - Country:US
Practice Address - Phone:671-477-2873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPA-110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant