Provider Demographics
NPI:1154472546
Name:PARK, EUGENE (LAC, PA-C)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:LAC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24A E EDSALL BLVD
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-3626
Mailing Address - Country:US
Mailing Address - Phone:323-304-4832
Mailing Address - Fax:
Practice Address - Street 1:458 WEST ST
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-3408
Practice Address - Country:US
Practice Address - Phone:201-474-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7437171100000X
CAAC8570171100000X
NJ25MZ00169700171100000X
NJ25MP00577600363A00000X
CAPA18721363A00000X
NY025055363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171100000XOther Service ProvidersAcupuncturist