Provider Demographics
NPI:1396133021
Name:PARK, CHRISTINA
Entity type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2888 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-7003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2888 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-7003
Practice Address - Country:US
Practice Address - Phone:706-245-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9004174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian