Provider Demographics
NPI:1366753022
Name:WASSON, MINA KIM (MD)
Entity type:Individual
Prefix:DR
First Name:MINA
Middle Name:KIM
Last Name:WASSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MINA
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3880 MURPHY CANYON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4411
Mailing Address - Country:US
Mailing Address - Phone:858-636-4300
Mailing Address - Fax:858-636-4319
Practice Address - Street 1:12395 EL CAMINO REAL STE 219
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3084
Practice Address - Country:US
Practice Address - Phone:858-793-1011
Practice Address - Fax:858-793-1035
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC167860208000000X
IL336100764208000000X
IL036132761208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty