Provider Demographics
NPI:1558723254
Name:PARK, KATHLEEN SIAPNO (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SIAPNO
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 BEACH CHANNEL DR
Mailing Address - Street 2:
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1288 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3909
Practice Address - Country:US
Practice Address - Phone:718-945-7150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297604-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics