Provider Demographics
NPI:1467708826
Name:PARK, BRUCE WOONG (LAC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:WOONG
Last Name:PARK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 58TH ST
Mailing Address - Street 2:APT 15J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2025
Mailing Address - Country:US
Mailing Address - Phone:646-262-6315
Mailing Address - Fax:
Practice Address - Street 1:200 E 58TH ST
Practice Address - Street 2:APT 15J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2025
Practice Address - Country:US
Practice Address - Phone:646-262-6315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004850171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist