Provider Demographics
NPI:1720793706
Name:PARK, SIWAN
Entity Type:Individual
Prefix:
First Name:SIWAN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1649 W ORANGETHORPE AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4535
Mailing Address - Country:US
Mailing Address - Phone:714-519-3883
Mailing Address - Fax:978-334-5369
Practice Address - Street 1:1649 W ORANGETHORPE AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4535
Practice Address - Country:US
Practice Address - Phone:714-519-3883
Practice Address - Fax:978-334-5369
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC19659171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist