Provider Demographics
NPI:1881604395
Name:PARK, JAMES T (APRN,FNP-C,DC)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:T
Last Name:PARK
Suffix:
Gender:M
Credentials:APRN,FNP-C,DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 LEXINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-3550
Mailing Address - Country:US
Mailing Address - Phone:817-335-2666
Mailing Address - Fax:817-335-2669
Practice Address - Street 1:904 LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-3550
Practice Address - Country:US
Practice Address - Phone:817-335-2666
Practice Address - Fax:817-335-2669
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6892111N00000X
TX1111605363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
605721Medicare ID - Type Unspecified
U67197Medicare UPIN