Provider Demographics
NPI:1114080801
Name:PARK, SUNYOUNG (LAC)
Entity Type:Individual
Prefix:
First Name:SUNYOUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:10801 FOOTHILL BLVD. # 104
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-989-4435
Mailing Address - Fax:909-989-4461
Practice Address - Street 1:10801 FOOTHILL BLVD. # 104
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-989-4435
Practice Address - Fax:909-989-4461
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11452171100000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171100000XOther Service ProvidersAcupuncturist