Provider Demographics
NPI:1265706402
Name:PARK, SU WON (NP)
Entity type:Individual
Prefix:
First Name:SU WON
Middle Name:
Last Name:PARK
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 S CROWLEY RD
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-3663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 S CROWLEY RD
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-3663
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX745143363LF0000X
TXAP121597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB152073Medicare PIN
TXTXB152072Medicare PIN
TXTXB152194Medicare PIN
TXTXB152071Medicare PIN