Provider Demographics
NPI:1265633077
Name:KIM, STACY JUNE (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:JUNE
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 1:4230 BURNHAM AVE
Mailing Address - Street 2:ASSOCIATED PATHOLOGISTS, CHARTERED
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5408
Mailing Address - Country:US
Mailing Address - Phone:702-733-7866
Mailing Address - Fax:702-792-1319
Practice Address - Street 1:4230 BURNHAM AVE
Practice Address - Street 2:ASSOCIATED PATHOLOGISTS, CHARTERED
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5408
Practice Address - Country:US
Practice Address - Phone:702-733-7866
Practice Address - Fax:702-792-1319
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108582207ZC0500X, 207ZP0102X
NV12851207ZC0500X, 207ZP0102X
PAMD430805207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV12851OtherMEDICAL LICENSE
NV1265633077Medicaid
CAA108582OtherMEDICAL LICENSE
CAA108582OtherMEDICAL LICENSE