Provider Demographics
NPI:1457470833
Name:PARK, JOSHUA DOUGLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:DOUGLAS
Last Name:PARK
Suffix:
Gender:M
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 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:1 BRACE RD STE H
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034
Practice Address - Country:US
Practice Address - Phone:856-547-0389
Practice Address - Fax:856-428-4053
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051536363A00000X
NJ25MP00600700363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ38055Medicare UPIN
PA088742NU9Medicare ID - Type Unspecified