Provider Demographics
NPI:1528205119
Name:PARKS, ALICIA SUE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:SUE
Last Name:PARKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:SUE
Other - Last Name:LONGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6370 W. UNION HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308
Mailing Address - Country:US
Mailing Address - Phone:623-414-3500
Mailing Address - Fax:623-455-9214
Practice Address - Street 1:6370 W. UNION HILLS DR.
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:623-414-3500
Practice Address - Fax:623-455-9214
Is Sole Proprietor?:No
Enumeration Date:2009-01-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4368363A00000X
NE1461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068731734Medicaid
NE10026293200Medicaid
NE47068731741Medicaid
NE10026480100Medicaid
NE47068731749Medicaid
NE47068731741Medicaid