Healthcare Provider Details

I. General information

NPI: 1568379501
Provider Name (Legal Business Name): LISA PARK
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 116TH AVE NE STE 209
BELLEVUE WA
98004-3825
US

IV. Provider business mailing address

1370 116TH AVE NE STE 209
BELLEVUE WA
98004-3825
US

V. Phone/Fax

Practice location:
  • Phone: 425-453-8406
  • Fax:
Mailing address:
  • Phone: 425-453-8406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAPRN.AP.70142159-NP
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: