Provider Demographics
NPI:1235187105
Name:PARKER, DARRELL R (PA-C)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:R
Last Name:PARKER
Suffix:
Gender:M
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 1:2825 HUNTERS TRL
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-3429
Mailing Address - Country:US
Mailing Address - Phone:608-742-7161
Mailing Address - Fax:608-475-3060
Practice Address - Street 1:2825 HUNTERS TRL
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-3429
Practice Address - Country:US
Practice Address - Phone:608-742-7161
Practice Address - Fax:608-725-3060
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI76-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1022697OtherPHYSICIANS PLUS
WI5878OtherDEAN HEALTH INSURANCE
WI42967300Medicaid
WI42967300Medicaid
WI5878OtherDEAN HEALTH INSURANCE
WI970004761Medicare PIN