Healthcare Provider Details

I. General information

NPI: 1245134709
Provider Name (Legal Business Name): GWENDOLYN PARK
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JOHN ST
KALAMAZOO MI
49007-5232
US

IV. Provider business mailing address

601 JOHN ST
KALAMAZOO MI
49007-5232
US

V. Phone/Fax

Practice location:
  • Phone: 269-341-7645
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: