Provider Demographics
NPI:1285665778
Name:PARK, ELVIN M (NP)
Entity Type:Individual
Prefix:MR
First Name:ELVIN
Middle Name:M
Last Name:PARK
Suffix:
Gender:M
Credentials:NP
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Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 N ROSE AVE STE 220
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-7640
Practice Address - Country:US
Practice Address - Phone:805-754-2811
Practice Address - Fax:805-754-2814
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA11908363LG0600X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP10163Medicare UPIN