Provider Demographics
NPI:1386316313
Name:PARK, MINA YOUNG (PT)
Entity type:Individual
Prefix:
First Name:MINA
Middle Name:YOUNG
Last Name:PARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 SE 36TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-1657
Mailing Address - Country:US
Mailing Address - Phone:425-653-7100
Mailing Address - Fax:452-653-7109
Practice Address - Street 1:14100 SE 36TH ST STE 210
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-1657
Practice Address - Country:US
Practice Address - Phone:425-653-7100
Practice Address - Fax:452-653-7109
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61204941225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist