Provider Demographics
NPI:1134812761
Name:PARK, TAE JOON (DNP, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TAE JOON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 S ROSE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-3759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:921 E FORT AVE STE 100
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-5135
Practice Address - Country:US
Practice Address - Phone:667-668-2566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR218239163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse