Provider Demographics
NPI:1003820010
Name:PARK, JANIE (RNFA)
Entity Type:Individual
Prefix:
First Name:JANIE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 W MEDINA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6848
Mailing Address - Country:US
Mailing Address - Phone:480-545-2610
Mailing Address - Fax:480-545-2673
Practice Address - Street 1:604 W MEDINA AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6848
Practice Address - Country:US
Practice Address - Phone:480-545-2610
Practice Address - Fax:480-545-2673
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN 032660363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1Z4903OtherHEALTHNET AZ
AZAZ0169450OtherBCBS AZ