Provider Demographics
NPI:1548714181
Name:PARK, ALLEN (PA-C)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 W DAISY CIR
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-4972
Mailing Address - Country:US
Mailing Address - Phone:815-325-1699
Mailing Address - Fax:
Practice Address - Street 1:1800 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2329
Practice Address - Country:US
Practice Address - Phone:815-325-1699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant