Provider Demographics
NPI:1457685786
Name:PARKER, LARRY JUAN JR (MED)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JUAN
Last Name:PARKER
Suffix:JR
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 ST THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-2999
Mailing Address - Country:US
Mailing Address - Phone:910-978-4128
Mailing Address - Fax:
Practice Address - Street 1:220 ST THOMAS RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-2999
Practice Address - Country:US
Practice Address - Phone:910-978-4128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-18
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98 00005101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP80624OtherETN