Provider Demographics
NPI:1538238423
Name:PARK, GARY (PTA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 CONCORD ST
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-1809
Mailing Address - Country:US
Mailing Address - Phone:816-322-2374
Mailing Address - Fax:
Practice Address - Street 1:13830 S 71 HIGHWAY
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030
Practice Address - Country:US
Practice Address - Phone:816-761-8088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO117830OtherLICENSE#