Provider Demographics
NPI:1144860404
Name:SHIN, BRIAN JISU (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JISU
Last Name:SHIN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8293 PERLA DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2419
Mailing Address - Country:US
Mailing Address - Phone:951-214-0212
Mailing Address - Fax:
Practice Address - Street 1:8293 PERLA DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-2419
Practice Address - Country:US
Practice Address - Phone:951-214-0212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA58316207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program