Basic Information
| Provider Information | |||||||||
| NPI: | 1437691870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | ANDREW | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24630 WASHNGTON AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516969353 | ||||||||
| FaxNumber: | 9519737216 | ||||||||
| Practice Location | |||||||||
| Address1: | 34617 11TH PL S STE 201 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538746620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2016 | ||||||||
| LastUpdateDate: | 12/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60691657 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 60691657 | 01 | WA | PT LICENSE | OTHER |