Provider Demographics
NPI:1407600141
Name:PARKER, ALYSSA R (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:R
Last Name:PARKER
Suffix:
Gender:F
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 1:8465 SHIRLEY CT APT 8
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4768
Mailing Address - Country:US
Mailing Address - Phone:810-845-1933
Mailing Address - Fax:
Practice Address - Street 1:1080 N 35TH ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053-9727
Practice Address - Country:US
Practice Address - Phone:269-665-7043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012324363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant