Basic Information
| Provider Information | |||||||||
| NPI: | 1174297857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | JANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1424 OUTLOOK AVE APT 1 | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104651184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188830012 | ||||||||
| FaxNumber: | 7189609361 | ||||||||
| Practice Location | |||||||||
| Address1: | 4422 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104572545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189609000 | ||||||||
| FaxNumber: | 7189609361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2021 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | F347367 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.