Provider Demographics
NPI:1982025714
Name:PARK, YOUNGSUN
Entity Type:Individual
Prefix:
First Name:YOUNGSUN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1979 ROCKAWAY PKWY
Mailing Address - Street 2:BROOKLYN
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5505
Mailing Address - Country:US
Mailing Address - Phone:718-531-1203
Mailing Address - Fax:
Practice Address - Street 1:1979 ROCKAWAY PKWY
Practice Address - Street 2:BROOKLYN
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-5505
Practice Address - Country:US
Practice Address - Phone:718-531-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF338273-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily