Provider Demographics
NPI:1134989866
Name:PARK, SAMANTHA ANN
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
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 1:1906 E BROADWAY AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4740
Mailing Address - Country:US
Mailing Address - Phone:701-415-6233
Mailing Address - Fax:833-525-1920
Practice Address - Street 1:1906 E BROADWAY AVE STE 1
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4740
Practice Address - Country:US
Practice Address - Phone:701-415-6233
Practice Address - Fax:833-525-1920
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDDUM00000171M00000X
ND175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator