Basic Information
| Provider Information | |||||||||
| NPI: | 1902252620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | CRNP FAMILY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6708 ACCIPITER DR | ||||||||
| Address2: | |||||||||
| City: | NEW MARKET | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217742933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406298065 | ||||||||
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| Practice Location | |||||||||
| Address1: | 610 SOLAREX CT | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217038624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016825500 | ||||||||
| FaxNumber: | 3016638557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2016 | ||||||||
| LastUpdateDate: | 08/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R168207 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 926580505 | 05 | MD | MEDICAID |