Provider Demographics
NPI:1902901838
Name:DO, PHUNG KIM (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:PHUNG
Middle Name:KIM
Last Name:DO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PHUNG
Other - Middle Name:KAREN
Other - Last Name:DO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:5254 PLANTER PL
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84118-1561
Mailing Address - Country:US
Mailing Address - Phone:801-968-3531
Mailing Address - Fax:
Practice Address - Street 1:4745 S 3200 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84118-2822
Practice Address - Country:US
Practice Address - Phone:801-964-6214
Practice Address - Fax:801-982-9232
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3083771-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP93919Medicare UPIN