Healthcare Provider Details

I. General information

NPI: 1902724669
Provider Name (Legal Business Name): YOUNG KUN PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 SUNSET HILLS RD UNIT 403
RESTON VA
20190-4780
US

IV. Provider business mailing address

11800 SUNSET HILLS RD UNIT 403
RESTON VA
20190-4780
US

V. Phone/Fax

Practice location:
  • Phone: 856-397-3933
  • Fax:
Mailing address:
  • Phone: 856-397-3933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019017722
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: