Provider Demographics
NPI:1760239867
Name:PARK, NATHAN JOON (MED)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:JOON
Last Name:PARK
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4383 PATRIOT PARK CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4333
Mailing Address - Country:US
Mailing Address - Phone:703-975-0095
Mailing Address - Fax:
Practice Address - Street 1:2960 CHAIN BRIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:OAKTON
Practice Address - State:VA
Practice Address - Zip Code:22124-3040
Practice Address - Country:US
Practice Address - Phone:703-490-0336
Practice Address - Fax:703-490-4525
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health