Provider Demographics
NPI:1720749278
Name:PARK, KWANG JIN (NP)
Entity type:Individual
Prefix:
First Name:KWANG
Middle Name:JIN
Last Name:PARK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7350 FUTURES DR STE 1
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-9082
Mailing Address - Country:US
Mailing Address - Phone:321-214-0028
Mailing Address - Fax:407-429-3833
Practice Address - Street 1:9400 TURKEY LAKE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8001
Practice Address - Country:US
Practice Address - Phone:407-351-8500
Practice Address - Fax:407-345-9765
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL11017162363LF0000X
FLAPRN11017162363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty