Provider Demographics
NPI:1336134113
Name:PARK, MATTHEW (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 HOSPITAL RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-9031
Mailing Address - Country:US
Mailing Address - Phone:740-779-8234
Mailing Address - Fax:740-779-7477
Practice Address - Street 1:272 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-9031
Practice Address - Country:US
Practice Address - Phone:740-779-7540
Practice Address - Fax:740-779-7867
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH280510367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2489838Medicaid
OH2489838Medicaid