Provider Demographics
NPI:1235393364
Name:PARK, VICTORIA FAGAN (FNP)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:FAGAN
Last Name:PARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:ANN
Other - Last Name:FAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 801606
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1606
Mailing Address - Country:US
Mailing Address - Phone:913-234-1350
Mailing Address - Fax:913-234-1108
Practice Address - Street 1:6400 PROSPECT AVE
Practice Address - Street 2:STE 310
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64132-1100
Practice Address - Country:US
Practice Address - Phone:816-926-0777
Practice Address - Fax:816-926-0707
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO091076163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSK22000001Medicare PIN