Provider Demographics
NPI:1760897557
Name:PARK, MATTHEW (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2942 SIERRA CREST WAY
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2942 SIERRA CREST WAY
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-6546
Practice Address - Country:US
Practice Address - Phone:323-842-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000181367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered