Provider Demographics
NPI:1083260095
Name:PARK, ANNA (NP)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2276 41ST ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1723
Mailing Address - Country:US
Mailing Address - Phone:831-420-7509
Mailing Address - Fax:
Practice Address - Street 1:4004 BOWNE ST APT 1I
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6129
Practice Address - Country:US
Practice Address - Phone:718-539-3359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309359363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health