Basic Information
| Provider Information | |||||||||
| NPI: | 1982827564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | TIERRA | ||||||||
| MiddleName: | DELA CRUZ | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | WYOMISSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196103335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103728044 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6TH AVE AND SPRUCE STREET | ||||||||
| Address2: | |||||||||
| City: | WEST READING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4846283637 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 08/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA21094 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.