Provider Demographics
NPI:1871619122
Name:PARK, LAWRENCE SOO-YOUNG (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:SOO-YOUNG
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1535
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401-1535
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-383-3553
Practice Address - Street 1:1304 FAWCETT AVE STE 100
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1900
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:253-383-3553
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010822552085R0202X
ORMD1622282085R0202X
WAMD600069652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0239075OtherLABOR AND INDUSTRIES-TRA
WA8948507OtherLABOR AND INDUSTRIES CRIME VICTIMS-TRA
WA8951845OtherLABOR AND INDUSTRIES CRIME VICTIMS-MEDICAL IMAGING ON 1ST
WA0239076OtherLABOR AND INDUSTRIES-UNION AVENUE OPEN MRI
WA0249563OtherLABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST
WAG8874925OtherPTAN-TRA PIERCE CO
WAG8874923OtherPTAN-TRA KING CO
WA8948507OtherLABOR AND INDUSTRIES CRIME VICTIMS-TRA
WA0239076OtherLABOR AND INDUSTRIES-UNION AVENUE OPEN MRI
WA40700Medicare PIN
WA1149PAMedicare PIN
WA8521130Medicare PIN
WAP03231Medicare PIN
WA0249563OtherLABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST
WA0239075OtherLABOR AND INDUSTRIES-TRA
WAP07252Medicare PIN
WA1055600Medicare PIN
WA8951845OtherLABOR AND INDUSTRIES CRIME VICTIMS-MEDICAL IMAGING ON 1ST
WA8948507OtherLABOR AND INDUSTRIES CRIME VICTIMS-TRA
WAG8874923OtherPTAN-TRA KING CO
WA255941Medicare PIN
WA0239076OtherLABOR AND INDUSTRIES-UNION AVENUE OPEN MRI
WAAB35572Medicare PIN
WAG8881464Medicare PIN