Provider Demographics
NPI:1134178965
Name:HYUN-PARK, YOUNGHAE LISA (MD)
Entity type:Individual
Prefix:
First Name:YOUNGHAE
Middle Name:LISA
Last Name:HYUN-PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:19455 DEERFIELD AVENUE, SUITE 204
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8102
Practice Address - Country:US
Practice Address - Phone:703-858-1500
Practice Address - Fax:703-858-5022
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050893207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1134178965Medicaid
VA30015843880001Medicaid