Provider Demographics
NPI:1568852317
Name:PARK, SONG Y (NP-C)
Entity Type:Individual
Prefix:
First Name:SONG
Middle Name:Y
Last Name:PARK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:SONIA
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSN, NP-C
Mailing Address - Street 1:23320 HIGHWAY 99
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8744
Mailing Address - Country:US
Mailing Address - Phone:425-640-5500
Mailing Address - Fax:
Practice Address - Street 1:23320 HIGHWAY 99
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8744
Practice Address - Country:US
Practice Address - Phone:425-640-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61211573363L00000X
GARN219551363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily