Provider Demographics
NPI:1366228314
Name:PARK, LYDIA SUNYOUNG (PA-C)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:SUNYOUNG
Last Name:PARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014-2209
Mailing Address - Country:US
Mailing Address - Phone:213-893-1960
Mailing Address - Fax:858-633-4700
Practice Address - Street 1:325 E 7TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90014-2209
Practice Address - Country:US
Practice Address - Phone:213-893-1960
Practice Address - Fax:858-633-4700
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63268363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant