Provider Demographics
NPI:1992056311
Name:PARK, SUN JA (MSRD)
Entity type:Individual
Prefix:MRS
First Name:SUN
Middle Name:JA
Last Name:PARK
Suffix:
Gender:F
Credentials:MSRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08629-2220
Mailing Address - Country:US
Mailing Address - Phone:609-599-5433
Mailing Address - Fax:609-475-4661
Practice Address - Street 1:1435 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08629-2220
Practice Address - Country:US
Practice Address - Phone:609-599-5433
Practice Address - Fax:609-475-4661
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0169129Medicaid