Healthcare Provider Details

I. General information

NPI: 1720749278
Provider Name (Legal Business Name): KWANG JIN PARK NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 TURKEY LAKE RD
ORLANDO FL
32819-8001
US

IV. Provider business mailing address

7350 FUTURES DR STE 1
ORLANDO FL
32819-9082
US

V. Phone/Fax

Practice location:
  • Phone: 407-351-8500
  • Fax: 407-345-9765
Mailing address:
  • Phone: 321-214-0028
  • Fax: 407-429-3833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11017162
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11017162
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: