Healthcare Provider Details

I. General information

NPI: 1952315426
Provider Name (Legal Business Name): YULIE J PARK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N PRAIRIE AVE
INGLEWOOD CA
90301-4501
US

IV. Provider business mailing address

PO BOX 10130
WESTMINSTER CA
92685-0130
US

V. Phone/Fax

Practice location:
  • Phone: 310-674-7050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA14109
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: