Provider Demographics
NPI:1033445663
Name:PARK, JAMIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 BELLE CHASSE HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-7127
Mailing Address - Country:US
Mailing Address - Phone:504-392-3131
Mailing Address - Fax:
Practice Address - Street 1:2500 BELLE CHASSE HIGHWAY
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-7127
Practice Address - Country:US
Practice Address - Phone:504-392-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03853756Medicaid
LA2119958Medicaid
MS03853756Medicaid