Provider Demographics
NPI:1457018384
Name:PARK, JIYEON
Entity Type:Individual
Prefix:
First Name:JIYEON
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2534 CRESCENT ST APT 2E
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2925
Mailing Address - Country:US
Mailing Address - Phone:718-730-2601
Mailing Address - Fax:
Practice Address - Street 1:2534 CRESCENT ST APT 2E
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-2925
Practice Address - Country:US
Practice Address - Phone:718-730-2601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-27
Last Update Date:2021-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF310534-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health