Provider Demographics
NPI:1285080846
Name:PARK, JUNGWON GENEVIEVE (MD, PHD)
Entity type:Individual
Prefix:
First Name:JUNGWON
Middle Name:GENEVIEVE
Last Name:PARK
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 N CHELAN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2025
Mailing Address - Country:US
Mailing Address - Phone:509-596-0096
Mailing Address - Fax:
Practice Address - Street 1:606 N CHELAN AVE STE B
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2025
Practice Address - Country:US
Practice Address - Phone:509-596-0096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61297103208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2260815Medicaid