Provider Demographics
NPI:1114545928
Name:PARKE, RAVEN (PA-C)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:PARKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 STONEWALL RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:VA
Mailing Address - Zip Code:24538-3070
Mailing Address - Country:US
Mailing Address - Phone:540-986-5480
Mailing Address - Fax:
Practice Address - Street 1:4035 ELECTRIC RD STE A
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-8449
Practice Address - Country:US
Practice Address - Phone:540-772-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00000000207PE0004X
VA0000000363A00000X
VA0110-007699363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant