Provider Demographics
NPI:1972000677
Name:PARK, DAVID JUNEWON (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JUNEWON
Last Name:PARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5235 BUFORD HWY NE
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30340-1106
Mailing Address - Country:US
Mailing Address - Phone:404-717-9051
Mailing Address - Fax:
Practice Address - Street 1:1825 EASTCHESTER RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2301
Practice Address - Country:US
Practice Address - Phone:718-904-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1140276363A00000X
GA8743363A00000X
NY024237363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA8743OtherGEORGIA PA LICENSE NUMBER
1140276OtherNCCPA PA LICENSE NUMBER