MEDICARE: JU YOUNG PARK N.P.

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	F340134	NY

General Provider Information

NPI Number	:	1750730206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JU YOUNG PARK N.P.

Provider Business Mailing Address
First Line	:	405 MAIN ST PH PH2B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10044-0349
Country	:	US
Telephone Number	:	505-459-5451
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 MAIN ST PH PH2B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10044-0349
Country	:	US
Telephone Number	:	505-459-5451
Fax Number	:

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

Provider Enumeration Date	:	06/06/2016
Last Update Date	:	06/06/2016

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