Healthcare Provider Details

I. General information

NPI: 1497146351
Provider Name (Legal Business Name): JIYOUN LEAH PARK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2015
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1468 MONTREAL RD
TUCKER GA
30084-6901
US

IV. Provider business mailing address

1468 MONTREAL RD
TUCKER GA
30084-6901
US

V. Phone/Fax

Practice location:
  • Phone: 770-638-1400
  • Fax:
Mailing address:
  • Phone: 770-638-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: