Provider Demographics
NPI:1801259379
Name:PARK, JOO WON
Entity type:Individual
Prefix:
First Name:JOO
Middle Name:WON
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 1:473B LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-3629
Mailing Address - Country:US
Mailing Address - Phone:201-245-9330
Mailing Address - Fax:
Practice Address - Street 1:473B LINCOLN ST
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-3629
Practice Address - Country:US
Practice Address - Phone:201-245-9330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY670366163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse