Provider Demographics
NPI:1619795424
Name:KIM, SANGJUNG
Entity type:Individual
Prefix:
First Name:SANGJUNG
Middle Name:
Last Name:KIM
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:GORYO APT 703 DONG - 602 HO, 8 JUNGGOK-RO
Mailing Address - Street 2:
Mailing Address - City:GEOJE-SI
Mailing Address - State:GYEONGSANGNAM-DO
Mailing Address - Zip Code:53249
Mailing Address - Country:KR
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 GOV CARLOS G CAMACHO RD
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3128
Practice Address - Country:US
Practice Address - Phone:671-647-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GU100181367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered