Provider Demographics
NPI:1760738728
Name:PARK, RYAN (NP)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 W TWINCOURT TRL STE 607-608
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8805
Mailing Address - Country:US
Mailing Address - Phone:904-230-3006
Mailing Address - Fax:877-638-8891
Practice Address - Street 1:559 W TWINCOURT TRL STE 607-608
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8805
Practice Address - Country:US
Practice Address - Phone:904-230-3006
Practice Address - Fax:877-638-8891
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11030031363L00000X
IDNP-1200A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty