Provider Demographics
NPI:1285687657
Name:PARK, KIL JA (CRNA)
Entity Type:Individual
Prefix:
First Name:KIL
Middle Name:JA
Last Name:PARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIL
Other - Middle Name:JA
Other - Last Name:YOU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10824
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-0824
Mailing Address - Country:US
Mailing Address - Phone:205-322-1808
Mailing Address - Fax:205-322-1851
Practice Address - Street 1:1000 W MORENO ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-2316
Practice Address - Country:US
Practice Address - Phone:850-437-8390
Practice Address - Fax:850-437-8394
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1099752367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG0131OtherBCBS
AL59170242OtherBCBS
AL59170243OtherBCBS
FLG0131OtherBCBS