Provider Demographics
NPI:1740235977
Name:PARK, MICHAEL CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:PARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:855-771-0335
Mailing Address - Fax:916-503-7513
Practice Address - Street 1:3133 PROFESSIONAL DR
Practice Address - Street 2:SUITE 20
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2463
Practice Address - Country:US
Practice Address - Phone:530-885-8821
Practice Address - Fax:530-885-6554
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16794363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP96721Medicare UPIN