Provider Demographics
NPI:1366927741
Name:KANG, SONG (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:SONG
Middle Name:
Last Name:KANG
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3727 N NORTHHAVEN CT APT 2A
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-9250
Mailing Address - Country:US
Mailing Address - Phone:618-201-9860
Mailing Address - Fax:
Practice Address - Street 1:320 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-4665
Practice Address - Country:US
Practice Address - Phone:217-877-4694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006761208D00000X
IN085006761363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice