Healthcare Provider Details

I. General information

NPI: 1669850525
Provider Name (Legal Business Name): YOUNG IN PARK D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 PACIFIC AVE STE 400
TACOMA WA
98402
US

IV. Provider business mailing address

1498 PACIFIC AVE STE 400
TACOMA WA
98402-4208
US

V. Phone/Fax

Practice location:
  • Phone: 855-768-6363
  • Fax:
Mailing address:
  • Phone: 855-768-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO2349
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberSL1082
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: