Provider Demographics
NPI:1700610532
Name:PARK, KYUWON (APRN)
Entity type:Individual
Prefix:
First Name:KYUWON
Middle Name:
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 1:2714 SE 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-0822
Mailing Address - Country:US
Mailing Address - Phone:352-615-3051
Mailing Address - Fax:
Practice Address - Street 1:910 OLD CAMP RD STE 210
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5605
Practice Address - Country:US
Practice Address - Phone:352-751-3356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11034023363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty