Provider Demographics
NPI:1477873107
Name:PARK, JAMIE (NP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:AIRMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10901-6302
Mailing Address - Country:US
Mailing Address - Phone:845-538-3767
Mailing Address - Fax:
Practice Address - Street 1:200 GRAND AVE STE 203
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4363
Practice Address - Country:US
Practice Address - Phone:201-588-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-04
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02200576964163W00000X
NJ26NR00439400363LF0000X
NYF337600-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse