1821449430 NPI number — JASON A PARK MD A PROFESSIONAL MEDICAL CORPORATION

Table of content: (NPI 1821449430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821449430 NPI number — JASON A PARK MD A PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JASON A PARK MD A PROFESSIONAL MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821449430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 EXPOSITION BLVD
Provider Second Line Business Mailing Address:
BUILDING 400 SUITE A
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95815-4314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-570-2840
Provider Business Mailing Address Fax Number:
916-570-2845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 EXPOSITION BLVD STE 400A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95815-4336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-570-2840
Provider Business Practice Location Address Fax Number:
916-570-2845
Provider Enumeration Date:
06/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LAIEWSKI
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
JEANNE
Authorized Official Title or Position:
ACCOUNTING MANAGER
Authorized Official Telephone Number:
916-570-2840

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  A62812 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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