Provider Demographics
NPI:1144322363
Name:PARK, RYAN SCOTT (OT-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:SCOTT
Last Name:PARK
Suffix:
Gender:M
Credentials:OT-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 N EL CAMINO REAL
Mailing Address - Street 2:SUITE 405
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2811
Mailing Address - Country:US
Mailing Address - Phone:760-942-0565
Mailing Address - Fax:
Practice Address - Street 1:317 N EL CAMINO REAL
Practice Address - Street 2:SUITE 405
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2811
Practice Address - Country:US
Practice Address - Phone:760-942-0565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA06-0806207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery