Provider Demographics
NPI:1245968973
Name:KIM, SUK CHUL (AG-ACNP)
Entity type:Individual
Prefix:
First Name:SUK CHUL
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-1165
Practice Address - Country:US
Practice Address - Phone:434-924-2409
Practice Address - Fax:434-982-4429
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR213897363LA2100X
VA0024185025363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care