Provider Demographics
NPI:1447458369
Name:PARK, JASON YISU (PT)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:YISU
Last Name:PARK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:YI SU
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3604 GALLEY RD.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-4301
Mailing Address - Country:US
Mailing Address - Phone:719-550-4613
Mailing Address - Fax:719-375-8426
Practice Address - Street 1:3604 GALLEY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-4302
Practice Address - Country:US
Practice Address - Phone:719-550-4613
Practice Address - Fax:719-375-8426
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42722241Medicaid
CO42722241Medicaid