Provider Demographics
NPI:1154334670
Name:PARK, YONGMOON ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:YONGMOON
Middle Name:ANDREW
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WA
Mailing Address - Zip Code:99328-1606
Mailing Address - Country:US
Mailing Address - Phone:509-382-3200
Mailing Address - Fax:509-382-2748
Practice Address - Street 1:1012 S 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:WA
Practice Address - Zip Code:99328-1606
Practice Address - Country:US
Practice Address - Phone:509-382-3200
Practice Address - Fax:509-382-2748
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48817207Q00000X
WAMD60173758174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAWA48817MMedicare PIN
WAE93201Medicare UPIN