Basic Information
| Provider Information | |||||||||
| NPI: | 1073253639 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | YOON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 171 TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | HARPERS FERRY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254253641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045356343 | ||||||||
| FaxNumber: | 3045962840 | ||||||||
| Practice Location | |||||||||
| Address1: | 171 TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | HARPERS FERRY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254253641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045356343 | ||||||||
| FaxNumber: | 3045962840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2022 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.