Provider Demographics
NPI:1215928072
Name:PARK, CHARLES (PA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SARGENT DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6100
Mailing Address - Country:US
Mailing Address - Phone:203-781-4444
Mailing Address - Fax:203-789-8341
Practice Address - Street 1:150 SARGENT DR
Practice Address - Street 2:SUITE 1
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6100
Practice Address - Country:US
Practice Address - Phone:203-781-4444
Practice Address - Fax:203-789-8341
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000001363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970011498OtherRAILROAD MEDICARE
CTS91545Medicare UPIN
CT970000444Medicare ID - Type Unspecified