Provider Demographics
NPI:1952813826
Name:PARK, SUE JIN (RN)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:JIN
Last Name:PARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 N MAIN ST STE 124
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-3013
Mailing Address - Country:US
Mailing Address - Phone:760-873-6533
Mailing Address - Fax:760-873-3277
Practice Address - Street 1:1360 N MAIN ST STE 124
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-3013
Practice Address - Country:US
Practice Address - Phone:760-873-6533
Practice Address - Fax:760-873-3277
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005086363LF0000X
CA840776163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily