Provider Demographics
NPI:1164645388
Name:PARKS, BRYAN SHAWN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:SHAWN
Last Name:PARKS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10390 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SCHOOLCRAFT
Mailing Address - State:MI
Mailing Address - Zip Code:49087-9444
Mailing Address - Country:US
Mailing Address - Phone:269-668-4787
Mailing Address - Fax:
Practice Address - Street 1:408 HAZEN ST
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1019
Practice Address - Country:US
Practice Address - Phone:269-657-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704202241367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI430H060120OtherBCBSM
MIH06012009Medicare PIN