Provider Demographics
NPI:1316941164
Name:PARK, JEFFREY D (CRNA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:PARK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 HOLME AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2007
Mailing Address - Country:US
Mailing Address - Phone:215-407-4848
Mailing Address - Fax:
Practice Address - Street 1:2601 HOLME AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19152-2007
Practice Address - Country:US
Practice Address - Phone:215-335-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN521643L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA054420HYTMedicare PIN
PA054420GDNMedicare PIN
PA054420Medicare PIN