Provider Demographics
NPI:1720049927
Name:PARK, STEVEN L (CRNA)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:L
Last Name:PARK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 S WHITE ST
Mailing Address - Street 2:N/A
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:IA
Mailing Address - Zip Code:52641-2262
Mailing Address - Country:US
Mailing Address - Phone:319-385-3141
Mailing Address - Fax:319-385-6571
Practice Address - Street 1:407 S WHITE ST
Practice Address - Street 2:N/A
Practice Address - City:MOUNT PLEASANT
Practice Address - State:IA
Practice Address - Zip Code:52641-2262
Practice Address - Country:US
Practice Address - Phone:319-385-3141
Practice Address - Fax:319-385-6571
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA069511367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA10051Medicare ID - Type UnspecifiedPROVIDING DR ID
IAR02988Medicare UPIN