Healthcare Provider Details

I. General information

NPI: 1336428440
Provider Name (Legal Business Name): ALYSSA MARIE PARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2011
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-1032
US

IV. Provider business mailing address

100 N ACADEMY AVE # 4903
DANVILLE PA
17822-9800
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6328
  • Fax: 570-271-6955
Mailing address:
  • Phone: 570-271-6144
  • Fax: 570-271-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD457758
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: