Healthcare Provider Details

I. General information

NPI: 1801510516
Provider Name (Legal Business Name): JOON PARK CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 01/02/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 UNIVERSITY BLVD E
SILVER SPRING MD
20901-2436
US

IV. Provider business mailing address

20 UNIVERSITY BLVD E
SILVER SPRING MD
20901-2436
US

V. Phone/Fax

Practice location:
  • Phone: 855-910-3278
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024185610
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP500004965
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR216697
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: