Provider Demographics
NPI:1033090345
Name:PARK, JUSTINA
Entity type:Individual
Prefix:
First Name:JUSTINA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CHAFFEE CIR
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07648-1248
Mailing Address - Country:US
Mailing Address - Phone:201-916-6611
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY433409363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care