Provider Demographics
NPI:1407659360
Name:PARK, KWANGHWI (RN)
Entity type:Individual
Prefix:
First Name:KWANGHWI
Middle Name:
Last Name:PARK
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15028 CROSS STONE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-4423
Mailing Address - Country:US
Mailing Address - Phone:201-787-1387
Mailing Address - Fax:
Practice Address - Street 1:2570 48TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1541
Practice Address - Country:US
Practice Address - Phone:916-734-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-28
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95272857163WC0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine