Provider Demographics
NPI:1417212812
Name:PARK, YOOJIN (MD)
Entity Type:Individual
Prefix:
First Name:YOOJIN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15214 CANYON RD E STE 120
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-7457
Mailing Address - Country:US
Mailing Address - Phone:253-539-4200
Mailing Address - Fax:253-944-6986
Practice Address - Street 1:15214 CANYON RD E STE 120
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-7457
Practice Address - Country:US
Practice Address - Phone:253-539-4200
Practice Address - Fax:253-944-6986
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60539959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2044629Medicaid
WA2044629Medicaid