Provider Demographics
NPI:1992347603
Name:PARK, DANIEL S (AUD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 SONOMA AVE STE 316
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4820
Mailing Address - Country:US
Mailing Address - Phone:707-523-4740
Mailing Address - Fax:
Practice Address - Street 1:1111 SONOMA AVE STE 316
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4820
Practice Address - Country:US
Practice Address - Phone:707-523-4740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU3371231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist