Healthcare Provider Details

I. General information

NPI: 1720077217
Provider Name (Legal Business Name): DR. YOUNG JA PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDCOM ATTS: DCCS-QM (CREDENTIALS)
APO AP
96205-0054
KR

IV. Provider business mailing address

18TH MEDCOM ATTN: DCCS-QM (CREDENTIALS)
APO AP
96295-0054
KR

V. Phone/Fax

Practice location:
  • Phone: 11-822-7916
  • Fax: 01182279178110
Mailing address:
  • Phone: 11-822-7916
  • Fax: 01182279178110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number133910-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: