Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0127X | Trauma Surgeon | A35787 | CA |
NPI | 1285772731 |
---|---|
Provider Name | Jin K Park |
First Address | Los Angeles, CA 90020-3049 |
Second Address | Los Angeles, CA 90020-3049 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A35787 | STATE LICENSE NUMBER (01) | CA |