Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 25MA05069000 | NJ |
Y | 2084N0402X | Child Neurologist | 25MA05069000 | NJ |
N | 2084N0600X | Clinical Neurophysiologist | 25MA05069000 | NJ |
NPI | 1053464545 |
---|---|
Provider Name | Jayoung Pak |
First Address | Newark, NJ 07107-3000 |
Second Address | Newark, NJ 07103-2425 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/01/2007 |
Last Update Date | 21/03/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5475708 | (05) | NJ |
F54424 | (02) | NJ |