Provider Demographics
NPI:1821449430
Name:JASON A PARK MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JASON A PARK MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:LAIEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-570-2840
Mailing Address - Street 1:1111 EXPOSITION BLVD
Mailing Address - Street 2:BUILDING 400 SUITE A
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4314
Mailing Address - Country:US
Mailing Address - Phone:916-570-2840
Mailing Address - Fax:916-570-2845
Practice Address - Street 1:1111 EXPOSITION BLVD STE 400A
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4336
Practice Address - Country:US
Practice Address - Phone:916-570-2840
Practice Address - Fax:916-570-2845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-24
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62812208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty