MEDICARE: JEONG YEON KANG PARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	ARNP9369012	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447793450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEONG YEON KANG PARK

Provider Business Mailing Address
First Line	:	2203 N LOIS AVE STE 814
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-2388
Country	:	US
Telephone Number	:	813-608-5633
Fax Number	:	800-608-5633

Provider Business Practice Location Address
First Line	:	2203 N LOIS AVE STE 814
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-2388
Country	:	US
Telephone Number	:	813-608-5633
Fax Number	:	800-608-5633

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2016
Last Update Date	:	12/12/2025

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Directions to “ JEONG YEON KANG PARK ” Practice Location

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