Healthcare Provider Details

I. General information

NPI: 1043359037
Provider Name (Legal Business Name): KYE SOO PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NE 87TH AVE
VANCOUVER WA
98664-1913
US

IV. Provider business mailing address

700 NE 87TH AVE
VANCOUVER WA
98664-1913
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-3370
  • Fax: 360-604-1749
Mailing address:
  • Phone: 360-397-3370
  • Fax: 360-604-1749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2004-0437
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD60145123
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: