Provider Demographics
NPI:1871031518
Name:PARK, SE J (NP-C)
Entity Type:Individual
Prefix:
First Name:SE
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:ANDREW
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:23961 CALLE DE LA MAGDALENA STE 500
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-7622
Mailing Address - Country:US
Mailing Address - Phone:949-844-5438
Mailing Address - Fax:949-844-5438
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA STE 500
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-7622
Practice Address - Country:US
Practice Address - Phone:949-855-1101
Practice Address - Fax:949-855-8710
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN243386363L00000X
CA95023379363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner