Provider Demographics
NPI:1174125595
Name:KANG, TAEUK (PA-C)
Entity type:Individual
Prefix:
First Name:TAEUK
Middle Name:
Last Name:KANG
Suffix:
Gender:M
Credentials:PA-C
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 2070
Mailing Address - Street 2:
Mailing Address - City:ORANGE GROVE
Mailing Address - State:TX
Mailing Address - Zip Code:78372-2070
Mailing Address - Country:US
Mailing Address - Phone:361-382-2024
Mailing Address - Fax:
Practice Address - Street 1:580 S DENTON TAP RD
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-4098
Practice Address - Country:US
Practice Address - Phone:972-462-0762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA15157363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA15157OtherTEXAS MEDICAL BOARD
TXPA15157OtherTEXAS MEDICAL BOARD