Provider Demographics
NPI:1811609100
Name:PARK, YOUNG IL (FNP)
Entity type:Individual
Prefix:MR
First Name:YOUNG
Middle Name:IL
Last Name:PARK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N MADISON AVE APT 103
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-2285
Mailing Address - Country:US
Mailing Address - Phone:213-308-0777
Mailing Address - Fax:
Practice Address - Street 1:525 N MADISON AVE APT 103
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-2285
Practice Address - Country:US
Practice Address - Phone:213-308-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95173940163W00000X
CA95023005363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse