Provider Demographics
NPI:1538162631
Name:PARK, DANIEL (PA)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-865-3700
Mailing Address - Fax:323-865-0120
Practice Address - Street 1:1441 EASTLAKE AVE
Practice Address - Street 2:STE 7416
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-2211
Practice Address - Country:US
Practice Address - Phone:323-865-3700
Practice Address - Fax:323-865-0120
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13945363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS93803Medicare UPIN
CAW16758Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
CAWPA13945BOtherPPID#
CAS93803Medicare UPIN
CAW16758Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
CADA4958OtherRR GROUP NUMBER