Provider Demographics
NPI:1578236568
Name:PARK, SANG- JUN
Entity Type:Individual
Prefix:
First Name:SANG- JUN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 DOUBLE CREEK DR STE 304
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-3831
Mailing Address - Country:US
Mailing Address - Phone:512-246-0220
Mailing Address - Fax:
Practice Address - Street 1:2251 DOUBLE CREEK DR STE 304
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-3831
Practice Address - Country:US
Practice Address - Phone:512-246-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01978171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist