Provider Demographics
NPI:1144417395
Name:PARK, KWAN (PT)
Entity type:Individual
Prefix:MR
First Name:KWAN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 NORTH CENRAL AVENUE
Mailing Address - Street 2:#260
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530
Mailing Address - Country:US
Mailing Address - Phone:914-683-7388
Mailing Address - Fax:
Practice Address - Street 1:111 N CENTRAL AVE
Practice Address - Street 2:#260
Practice Address - City:HARTSDALE
Practice Address - State:NY
Practice Address - Zip Code:10530-1903
Practice Address - Country:US
Practice Address - Phone:914-683-7388
Practice Address - Fax:914-683-8419
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025679225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist