Provider Demographics
NPI:1477389773
Name:PARK, JOHN JOOHUN (APRN)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JOOHUN
Last Name:PARK
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 W SPRINGFIELD AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-3098
Mailing Address - Country:US
Mailing Address - Phone:217-530-0220
Mailing Address - Fax:
Practice Address - Street 1:1907 W SPRINGFIELD AVE STE B
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-3098
Practice Address - Country:US
Practice Address - Phone:217-530-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-12
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209030497207R00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine