Healthcare Provider Details

I. General information

NPI: 1477389773
Provider Name (Legal Business Name): JOHN JOOHUN PARK APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 W SPRINGFIELD AVE STE B
CHAMPAIGN IL
61821-3098
US

IV. Provider business mailing address

1907 W SPRINGFIELD AVE STE B
CHAMPAIGN IL
61821-3098
US

V. Phone/Fax

Practice location:
  • Phone: 217-530-0220
  • Fax:
Mailing address:
  • Phone: 217-530-0220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209030497
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number209030497
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: