Provider Demographics
NPI:1982159091
Name:PARK, JINSU
Entity Type:Individual
Prefix:
First Name:JINSU
Middle Name:
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 1:3030 ANTIETAM CT
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-4901
Mailing Address - Country:US
Mailing Address - Phone:831-917-8379
Mailing Address - Fax:
Practice Address - Street 1:3030 ANTIETAM CT
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-4901
Practice Address - Country:US
Practice Address - Phone:831-917-8379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program