Healthcare Provider Details

I. General information

NPI: 1144686577
Provider Name (Legal Business Name): TONY JUNGWOO PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7212 ORANGETHORPE AVE STE 9A
BUENA PARK CA
90621-4668
US

IV. Provider business mailing address

53 SCARLET BLOOM
IRVINE CA
92618-8808
US

V. Phone/Fax

Practice location:
  • Phone: 714-503-6550
  • Fax: 714-409-3075
Mailing address:
  • Phone: 858-740-4142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number835101
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95003723
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2020011541
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: