Provider Demographics
NPI:1548742380
Name:PARK, JANAL MINJI (PA-C)
Entity Type:Individual
Prefix:
First Name:JANAL
Middle Name:MINJI
Last Name:PARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JANAL
Other - Middle Name:MINJI
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 741515
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-1515
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-341-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WAPA61009763363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2176744Medicaid