Provider Demographics
NPI:1982827564
Name:PARK, TIERRA DELA CRUZ (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TIERRA
Middle Name:DELA CRUZ
Last Name:PARK
Suffix:
Gender:F
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 1:50 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-3335
Mailing Address - Country:US
Mailing Address - Phone:610-372-8044
Mailing Address - Fax:
Practice Address - Street 1:6TH AVE AND SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611
Practice Address - Country:US
Practice Address - Phone:484-628-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21094363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA229090Medicare PIN