Provider Demographics
NPI:1124400858
Name:PARK, ANDREW (DPM)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 S COLUMBIAN WAY # 112-POD
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-1532
Mailing Address - Country:US
Mailing Address - Phone:206-762-1010
Mailing Address - Fax:
Practice Address - Street 1:27500 168TH PL SE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-5563
Practice Address - Country:US
Practice Address - Phone:425-690-3430
Practice Address - Fax:425-690-9430
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO60788616213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist