Provider Demographics
NPI:1568845816
Name:PARK, PAULA LEEANNE (DPT)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:LEEANNE
Last Name:PARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:LEEANNE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:106 QUAIL POINT CIR
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-1966
Mailing Address - Country:US
Mailing Address - Phone:785-250-1755
Mailing Address - Fax:
Practice Address - Street 1:106 QUAIL POINT CIR
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066
Practice Address - Country:US
Practice Address - Phone:785-250-1755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-06
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293252225100000X
KS225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist