Provider Demographics
NPI:1962831537
Name:PARK, MINNA (NP)
Entity Type:Individual
Prefix:
First Name:MINNA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 W 100TH ST
Mailing Address - Street 2:APT 920
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5018
Mailing Address - Country:US
Mailing Address - Phone:347-768-1551
Mailing Address - Fax:
Practice Address - Street 1:16410 NORTHERN BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-2677
Practice Address - Country:US
Practice Address - Phone:718-321-2940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337877363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily