MEDICARE: MRS. NURI PARK NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	NP16060	CA

General Provider Information

NPI Number	:	1003955667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NURI PARK NP

Provider Business Mailing Address
First Line	:	750 N SAINT PAUL ST STE 1340
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-7111
Country	:	US
Telephone Number	:	855-961-1942
Fax Number	:	866-702-0882

Provider Business Practice Location Address
First Line	:	750 N SAINT PAUL ST STE 1340
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-7111
Country	:	US
Telephone Number	:	855-961-1942
Fax Number	:	866-702-0882

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	12/01/2021

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