Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP2300X | Nurse Practitioner - Primary Care | 2307013 | MA |
NPI | 1013570605 |
---|---|
Provider Name | Changhee Park |
First Address | Boston, MA 02108-4720 |
Second Address | Boston, MA 02108-4720 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/04/2019 |
Last Update Date | 18/04/2019 |