Provider Demographics
NPI:1851902571
Name:PARK, TOMOYO (PA-C)
Entity Type:Individual
Prefix:
First Name:TOMOYO
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TOMOYO
Other - Middle Name:
Other - Last Name:OHARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:720 W OAK ST STE 360
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4910
Mailing Address - Country:US
Mailing Address - Phone:407-846-0090
Mailing Address - Fax:
Practice Address - Street 1:720 W OAK ST STE 360
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4910
Practice Address - Country:US
Practice Address - Phone:407-846-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty