Provider Demographics
NPI:1184292419
Name:PARK, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 CHIPETA AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2748
Mailing Address - Country:US
Mailing Address - Phone:808-599-0563
Mailing Address - Fax:
Practice Address - Street 1:2373 G RD STE 270
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1006
Practice Address - Country:US
Practice Address - Phone:970-644-3800
Practice Address - Fax:970-644-3946
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0008210363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program