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General NPI Number Information
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NPI Number | 1225741952
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Entity Type | Individual
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Provider Name | DANIEL S PARK PA-C
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Gender | Male
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Dates
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Enumeration Date | 12/27/2022
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Last Update Date | 12/27/2022
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Provider Practice Location Address
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Address Line | 200 BRULE ST BLDG 871
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City | FORT KNOX
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State | KY
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Zip | 40121-6100
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Country | US
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Telephone | 502-624-9333
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Fax |
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Provider Business Mailing Address
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Address Line | 1166 NE LAUREL CT
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City | ISSAQUAH
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State | WA
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Zip | 98029-7676
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Country | US
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Telephone | 206-778-9459
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number |
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License Number State |
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