MEDICARE: JUNG NAM PARK

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	363LF0000X	Family Nurse Practitioner	NP95014875	CA

General Provider Information

NPI Number	:	1275118119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUNG NAM PARK

Provider Business Mailing Address
First Line	:	215 S IMPERIAL HWY
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92807-3966
Country	:	US
Telephone Number	:	408-710-7033
Fax Number	:

Provider Business Practice Location Address
First Line	:	2120 W 8TH ST STE 102
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-4081
Country	:	US
Telephone Number	:	213-382-2700
Fax Number	:	213-382-5077

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

Provider Enumeration Date	:	03/12/2021
Last Update Date	:	03/12/2021

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Directions to “ JUNG NAM PARK ” Practice Location

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