Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | SP015055 | PA |
NPI | 1003290404 |
---|---|
Provider Name | Jamie L Park |
First Address | Greenville, PA 16125-2060 |
Second Address | Greenville, PA 16125-2060 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2015 |
Last Update Date | 15/07/2015 |