Provider Demographics
NPI:1285194134
Name:PARKER, BRENT EARL JR (ATP)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:EARL
Last Name:PARKER
Suffix:JR
Gender:M
Credentials:ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 E 200 N
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5954
Mailing Address - Country:US
Mailing Address - Phone:702-496-2784
Mailing Address - Fax:
Practice Address - Street 1:4715 E 200 N
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5954
Practice Address - Country:US
Practice Address - Phone:702-496-2784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3586332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment