Provider Demographics
NPI:1417999491
Name:PARK, SUE YOUNG (MD)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:YOUNG
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 1:410 CHURCH ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0222
Mailing Address - Country:US
Mailing Address - Phone:612-625-8400
Mailing Address - Fax:612-625-1434
Practice Address - Street 1:410 CHURCH ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0222
Practice Address - Country:US
Practice Address - Phone:612-625-8400
Practice Address - Fax:612-625-1434
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36666207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN037817800Medicaid
MNF71865Medicare UPIN
MN080002981Medicare ID - Type Unspecified