Provider Demographics
NPI:1801645742
Name:PARK, NOMIN (NP)
Entity type:Individual
Prefix:
First Name:NOMIN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 E MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7140
Mailing Address - Country:US
Mailing Address - Phone:541-292-7639
Mailing Address - Fax:
Practice Address - Street 1:1003 E MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7140
Practice Address - Country:US
Practice Address - Phone:541-779-1282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-14
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10026206164W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No164W00000XNursing Service ProvidersLicensed Practical Nurse