Healthcare Provider Details

I. General information

NPI: 1063477016
Provider Name (Legal Business Name): JI HYE PARK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PLAZA DR
ROSEVILLE CA
95661-3037
US

IV. Provider business mailing address

1 MEDICAL PLAZA DR
ROSEVILLE CA
95661-3037
US

V. Phone/Fax

Practice location:
  • Phone: 916-781-5000
  • Fax: 916-781-5055
Mailing address:
  • Phone: 323-580-1382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15502
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: