Provider Demographics
NPI:1487224036
Name:PARKER, JEFFERY MITCHELL (PA)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:MITCHELL
Last Name:PARKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2464 BROOKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-1418
Mailing Address - Country:US
Mailing Address - Phone:785-341-7305
Mailing Address - Fax:
Practice Address - Street 1:1133 COLLEGE AVE STE G100
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2756
Practice Address - Country:US
Practice Address - Phone:785-537-8710
Practice Address - Fax:785-537-0562
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-27
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS15-02535363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS15418963OtherCAQH ID 15418963