Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 25MD00365800 | NJ |
Y | 222Z00000X | Podiatrist | 25MD00365800 | NJ |
N | 213E00000X | Podiatrist | N00721001 | NY |
N | 222Z00000X | Podiatrist | N00721001 | NY |
N | 213E00000X | Podiatrist | POD001311 | GA |
N | 222Z00000X | Podiatrist | POD001311 | GA |
N | 213EP1101X | Primary Podiatric Medicine | 25MD00365800 | NJ |
N | 213ES0103X | Foot & Ankle Surgery | 25MD00365800 | NJ |
NPI | 1396088803 |
---|---|
Provider Name | Dr. Jae Yoon Shin |
First Address | Long Island City, NY 11101-8618 |
Second Address | Long Island City, NY 11101-8618 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2013 |
Last Update Date | 01/02/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
25MD00365800 | PODIATRIC LICENSE (01) | NJ |
N007210-01 | PODIATRIC LICENSE (01) | NY |
POD001311 | PODIATRIC LICENSE (01) | GA |