Provider Demographics
NPI:1902965452
Name:KIM, HEESUN NINA (MD)
Entity Type:Individual
Prefix:
First Name:HEESUN
Middle Name:NINA
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11995 SINGLETREE LN
Mailing Address - Street 2:STE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:705 AUGUSTA DR
Practice Address - Street 2:
Practice Address - City:BRIDGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15017-3437
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4238832085B0100X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA808011OtherBLUE SHIELD
PAG96767Medicare UPIN
PAMD423883OtherLICENSE NUMBER