Provider Demographics
NPI:1295823276
Name:PARKER, LELAND E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LELAND
Middle Name:E
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 1:21 ELM ST
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-2915
Mailing Address - Country:US
Mailing Address - Phone:860-210-7490
Mailing Address - Fax:860-350-7297
Practice Address - Street 1:21 ELM ST
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-2915
Practice Address - Country:US
Practice Address - Phone:860-210-7490
Practice Address - Fax:860-350-7297
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001741363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTQ68193Medicare UPIN