Provider Demographics
NPI:1932668423
Name:PARK, KAITLYN MIN (NP)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MIN
Last Name:PARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:J
Other - Last Name:MIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3452 E FOOTHILL BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-6006
Mailing Address - Country:US
Mailing Address - Phone:626-793-2885
Mailing Address - Fax:626-793-6262
Practice Address - Street 1:625 S FAIR OAKS AVE STE 215
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2613
Practice Address - Country:US
Practice Address - Phone:626-793-4139
Practice Address - Fax:626-304-8280
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010268363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily