Provider Demographics
NPI:1104662873
Name:PARK, SOH YOUNG (AP,DOM)
Entity type:Individual
Prefix:
First Name:SOH YOUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:AP,DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4627 BURKETT CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-6207
Mailing Address - Country:US
Mailing Address - Phone:813-573-2756
Mailing Address - Fax:
Practice Address - Street 1:17501 N DALE MABRY HWY # D
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4521
Practice Address - Country:US
Practice Address - Phone:813-573-2756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4565171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist