Provider Demographics
NPI:1396168480
Name:PARK, SEOUN H (ANP)
Entity type:Individual
Prefix:MS
First Name:SEOUN
Middle Name:H
Last Name:PARK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16A MARA RD
Mailing Address - Street 2:
Mailing Address - City:LAKE HIAWATHA
Mailing Address - State:NJ
Mailing Address - Zip Code:07034-1350
Mailing Address - Country:US
Mailing Address - Phone:201-602-2726
Mailing Address - Fax:
Practice Address - Street 1:992 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3502
Practice Address - Country:US
Practice Address - Phone:862-249-1266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY680166163W00000X
NJ26NJ15069000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse