Basic Information
| Provider Information | |||||||||
| NPI: | 1639589047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIM | ||||||||
| FirstName: | MISUN | ||||||||
| MiddleName: | PARK | ||||||||
| NamePrefix: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PARK | ||||||||
| OtherFirstName: | MI SUN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1340 S DAMEN AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606081169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732924800 | ||||||||
| FaxNumber: | 3125644059 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 S WARNER RD STE 310 | ||||||||
| Address2: | |||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194062860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732924800 | ||||||||
| FaxNumber: | 3125644059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2014 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | SP013516 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.