Provider Demographics
NPI:1902016314
Name:PARK, AUDREY Y (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:Y
Last Name:PARK
Suffix:
Gender:F
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9725 3RD AVE NE STE 500
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-2024
Mailing Address - Country:US
Mailing Address - Phone:206-527-1200
Mailing Address - Fax:206-527-2514
Practice Address - Street 1:9725 3RD AVE NE STE 500
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2024
Practice Address - Country:US
Practice Address - Phone:206-527-1200
Practice Address - Fax:206-527-2514
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60077988207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60077988OtherPHYSICIANS LICENSE
WAMD60077988OtherPHYSICIANS LICENSE
WAG8884932Medicare PIN
WAG8884935Medicare PIN
WAG8884934Medicare PIN