Provider Demographics
NPI:1083205801
Name:PARKER, JOSHUA RIDIKAS
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:RIDIKAS
Last Name:PARKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 EBENEZER CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-5201
Mailing Address - Country:US
Mailing Address - Phone:770-639-7949
Mailing Address - Fax:
Practice Address - Street 1:168 EBENEZER CHURCH RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-5201
Practice Address - Country:US
Practice Address - Phone:770-639-7949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0028792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty