Provider Demographics
NPI:1376129841
Name:PARK, KACI (PA-C)
Entity Type:Individual
Prefix:
First Name:KACI
Middle Name:
Last Name:PARK
Suffix:
Gender:F
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 1:1000 E 23RD ST STE 360
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-2140
Mailing Address - Country:US
Mailing Address - Phone:605-322-3950
Mailing Address - Fax:
Practice Address - Street 1:1000 E 23RD ST STE 360
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-2140
Practice Address - Country:US
Practice Address - Phone:605-322-3950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant