Provider Demographics
NPI:1538179619
Name:PARK, DEBORA LYNN
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:LYNN
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 1:6135 KING ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-8877
Mailing Address - Country:US
Mailing Address - Phone:916-652-0427
Mailing Address - Fax:916-652-4197
Practice Address - Street 1:6135 KING ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:LOOMIS
Practice Address - State:CA
Practice Address - Zip Code:95650-8877
Practice Address - Country:US
Practice Address - Phone:916-652-0427
Practice Address - Fax:916-652-4197
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHP72501247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist