Provider Demographics
NPI:1215374848
Name:PARK, JIN YOUNG (FNP-BC)
Entity type:Individual
Prefix:
First Name:JIN
Middle Name:YOUNG
Last Name:PARK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3408
Mailing Address - Country:US
Mailing Address - Phone:541-762-4325
Mailing Address - Fax:541-762-0740
Practice Address - Street 1:195 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3408
Practice Address - Country:US
Practice Address - Phone:541-762-4325
Practice Address - Fax:541-762-0740
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201402848RN163W00000X
CA818327163W00000X
CA95000717363LF0000X
OR201403802NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA818327OtherREGISTERED NURSE