Provider Demographics
NPI:1003112814
Name:PARK, RUSTIN JIN (RN, BSN)
Entity Type:Individual
Prefix:MR
First Name:RUSTIN
Middle Name:JIN
Last Name:PARK
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 E CHARLESTON BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-6659
Mailing Address - Country:US
Mailing Address - Phone:702-968-4020
Mailing Address - Fax:702-968-4040
Practice Address - Street 1:4000 E CHARLESTON BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-6659
Practice Address - Country:US
Practice Address - Phone:702-968-4020
Practice Address - Fax:702-968-4040
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN65754163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health