Provider Demographics
NPI:1225741952
Name:PARK, DANIEL S (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1166 NE LAUREL CT
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-7676
Mailing Address - Country:US
Mailing Address - Phone:206-778-9459
Mailing Address - Fax:
Practice Address - Street 1:200 BRULE ST BLDG 871
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-6100
Practice Address - Country:US
Practice Address - Phone:502-624-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1204605OtherNCCPA IDENTIFICATION NUMBER