Provider Demographics
NPI:1508474925
Name:PARK, CHRIS (RRT)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12025 COPPER MINE LN
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79934-3416
Mailing Address - Country:US
Mailing Address - Phone:917-344-0105
Mailing Address - Fax:
Practice Address - Street 1:12025 COPPER MINE LN
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79934-3416
Practice Address - Country:US
Practice Address - Phone:917-344-0105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011014227900000X
NMRCP4215227900000X
TXRCP02003035227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX43645453OtherDRIVER LICENSE