MEDICARE: MR. JASON YISU PARK P.T

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	225100000X	Physical Therapist	8470	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447458369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON YISU PARK P.T

Provider Business Mailing Address
First Line	:	3604 GALLEY RD.
Second Line	:	SUITE 200
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-4301
Country	:	US
Telephone Number	:	719-550-4613
Fax Number	:	719-375-8426

Provider Business Practice Location Address
First Line	:	3604 GALLEY RD
Second Line	:	SUITE 200
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-4302
Country	:	US
Telephone Number	:	719-550-4613
Fax Number	:	719-375-8426

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

Provider Enumeration Date	:	07/03/2007
Last Update Date	:	02/02/2016

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