Provider Demographics
NPI:1437691870
Name:PARK, ANDREW (DPT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6177 KIRK ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4636
Mailing Address - Country:US
Mailing Address - Phone:253-431-8046
Mailing Address - Fax:
Practice Address - Street 1:9900 INDIANA AVE STE 8
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5498
Practice Address - Country:US
Practice Address - Phone:951-376-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60691657225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60691657OtherPT LICENSE
CAPT304206OtherPT LICENSE