Provider Demographics
NPI:1679195754
Name:PARK, SHIN WOOK (PTA)
Entity Type:Individual
Prefix:
First Name:SHIN WOOK
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10014 NE 127TH PL APT A205
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-8804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15315 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:DUVALL
Practice Address - State:WA
Practice Address - Zip Code:98019-5004
Practice Address - Country:US
Practice Address - Phone:425-788-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160925668225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant