Provider Demographics
NPI:1306255336
Name:PARK, YAENA (DO)
Entity type:Individual
Prefix:
First Name:YAENA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 BLAIR MILL RD
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1041
Mailing Address - Country:US
Mailing Address - Phone:215-672-7070
Mailing Address - Fax:215-672-6426
Practice Address - Street 1:2701 BLAIR MILL RD
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1041
Practice Address - Country:US
Practice Address - Phone:215-672-7070
Practice Address - Fax:215-672-6426
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT016531207Q00000X
390200000X
WAOP60842364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2108259Medicaid