Basic Information
| Provider Information | |||||||||
| NPI: | 1871619122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | SOO-YOUNG | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1535 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984011535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Practice Location | |||||||||
| Address1: | 1304 FAWCETT AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984021900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD162228 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 4301082255 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD60006965 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0249563 | 01 | WA | LABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST | OTHER | 0239076 | 01 | WA | LABOR AND INDUSTRIES-UNION AVENUE OPEN MRI | OTHER | 0239075 | 01 | WA | LABOR AND INDUSTRIES-TRA | OTHER | 8948507 | 01 | WA | LABOR AND INDUSTRIES CRIME VICTIMS-TRA | OTHER | 8951845 | 01 | WA | LABOR AND INDUSTRIES CRIME VICTIMS-MEDICAL IMAGING ON 1ST | OTHER |