Provider Demographics
NPI:1962671545
Name:PARK, SE JONG (CST AS-C)
Entity Type:Individual
Prefix:
First Name:SE JONG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:CST AS-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 ILLSLEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-5110
Mailing Address - Country:US
Mailing Address - Phone:207-756-3621
Mailing Address - Fax:888-329-6432
Practice Address - Street 1:51 ILLSLEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-5110
Practice Address - Country:US
Practice Address - Phone:207-756-3621
Practice Address - Fax:888-329-6432
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant