Provider Demographics
NPI:1851840342
Name:PARK, YEJI ESTHER
Entity Type:Individual
Prefix:
First Name:YEJI
Middle Name:ESTHER
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 WILSHIRE BLVD APT 545
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4896
Mailing Address - Country:US
Mailing Address - Phone:410-948-4679
Mailing Address - Fax:
Practice Address - Street 1:16745 W BERNARDO DR STE 240
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1908
Practice Address - Country:US
Practice Address - Phone:858-592-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004868363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner