MEDICARE: CHRISTINE PARK CPNP

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	363LP0200X	Pediatric Nurse Practitioner	R134132-8	MN

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	:	1730188699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE PARK CPNP

Provider Business Mailing Address
First Line	:	2910 CENTRE POINTE DR
Second Line	:	35-121A
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-1182
Country	:	US
Telephone Number	:	651-855-2327
Fax Number	:	651-855-2310

Provider Business Practice Location Address
First Line	:	347 SMITH AVE N
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55102-2387
Country	:	US
Telephone Number	:	651-220-6789
Fax Number	:	651-220-6807

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

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	11/30/2007

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