Provider Demographics
NPI:1255483913
Name:PARKS, MELISSA L (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:PARKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18700 N 64TH DR
Mailing Address - Street 2:STE 301
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7109
Mailing Address - Country:US
Mailing Address - Phone:623-561-5437
Mailing Address - Fax:623-561-2316
Practice Address - Street 1:18700 N 64TH DR
Practice Address - Street 2:301
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7109
Practice Address - Country:US
Practice Address - Phone:623-561-5437
Practice Address - Fax:623-561-9320
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3489363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ161011Medicaid