Provider Demographics
NPI:1194379719
Name:PARK, WESLEY (BA, BS)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:BA, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 HOES LN W RM N-100
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-8021
Mailing Address - Country:US
Mailing Address - Phone:732-395-7895
Mailing Address - Fax:
Practice Address - Street 1:277 GEORGE ST
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1476
Practice Address - Country:US
Practice Address - Phone:732-406-9131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program