Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 13322 | NV |
N | 207QS0010X | Family Doctor - Sports Medicine | 13322 | NV |
N | 207QS0010X | Family Doctor - Sports Medicine | A98140 | CA |
NPI | 1003070640 |
---|---|
Provider Name | Dr. Susan Jin-Sun Park |
First Address | Reno, NV 89502-1576 |
Second Address | Reno, NV 89511 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2008 |
Last Update Date | 21/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12139950 | CAQH (01) |