Provider Demographics
NPI:1720077217
Name:PARK, YOUNG JA
Entity Type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:JA
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18TH MEDCOM
Mailing Address - Street 2:ATTN: DCCS-QM (CREDENTIALS)
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96295-0054
Mailing Address - Country:KR
Mailing Address - Phone:011-822-7916
Mailing Address - Fax:0118227-917-8110
Practice Address - Street 1:18TH MEDCOM
Practice Address - Street 2:ATTS: DCCS-QM (CREDENTIALS)
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-0054
Practice Address - Country:KR
Practice Address - Phone:011-822-7916
Practice Address - Fax:0118227-917-8110
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133910-1171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider