Provider Demographics
NPI:1710354907
Name:PARK, MIJEONG (CPNP)
Entity Type:Individual
Prefix:
First Name:MIJEONG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:27721 STATE HIGHWAY 249 STE 100
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-6579
Mailing Address - Country:US
Mailing Address - Phone:281-357-5115
Mailing Address - Fax:
Practice Address - Street 1:12015 LOUETTA RD STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-1148
Practice Address - Country:US
Practice Address - Phone:281-664-2152
Practice Address - Fax:281-257-3514
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007911363LP0200X
TXAP135474363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1579732OtherWELLPATH
NC1710354907OtherHUMANA
NC1710354907OtherDOCTORS DIRECT
NC1710354907OtherHEALTHNET FEDERAL SERVICES
NC298447OtherMEDCOST
NC4632274OtherCOVENTRY NATIONAL - COVENTRY PPO
NCFH4002315OtherFIRST CAROLINA CARE
NC1579732OtherCOVENTRY OF THE CAROLINAS
TX1710354907Medicaid
NC4948746OtherAETNA
NC135452367OtherPHCS/MULTIPLAN
NC1710354907OtherHEALTHSMART
NC1710354907Medicaid
NC19EFKOtherBCBS OF NC
NC3455644OtherCIGNA/GREATWEST
NC5707800OtherUNITED HEALTHCARE