Healthcare Provider Details

I. General information

NPI: 1912169574
Provider Name (Legal Business Name): PATRICK CHIHO PARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WEST AVE S
LA CROSSE WI
54601-4783
US

IV. Provider business mailing address

PO BOX 1510
EAU CLAIRE WI
54702-1510
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-0940
  • Fax:
Mailing address:
  • Phone: 608-785-0940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number57481
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125055003
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: