Provider Demographics
NPI:1548461221
Name:PARK, SUSAN S (PNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
Last Name:PARK
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:S
Other - Last Name:PARK-CHUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1814
Mailing Address - Fax:602-933-1820
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-3366
Practice Address - Fax:602-933-4166
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY583996363LP0200X
AZRN159828/AP3469363LP0200X
AZAP3469363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ471651Medicaid