MEDICARE: MR. DANIEL PARK P.A.

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	363A00000X	Physician Assistant	PA13945	CA
2	363AM0700X	Medical Physician Assistant	PA13945	CA
3	363AS0400X	Surgical Physician Assistant	PA13945	CA

General Provider Information

NPI Number	:	1538162631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DANIEL PARK P.A.

Provider Business Mailing Address
First Line	:	PO BOX 31309
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-0309
Country	:	US
Telephone Number	:	323-865-3700
Fax Number	:	323-865-0120

Provider Business Practice Location Address
First Line	:	1441 EASTLAKE AVE
Second Line	:	STE 7416
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-2211
Country	:	US
Telephone Number	:	323-865-3700
Fax Number	:	323-865-0120

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	02/03/2023

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