Provider Demographics
NPI:1659889327
Name:PARKER, AMMON R (CRNA)
Entity Type:Individual
Prefix:
First Name:AMMON
Middle Name:R
Last Name:PARKER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3570
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3570
Mailing Address - Country:US
Mailing Address - Phone:801-727-2056
Mailing Address - Fax:770-701-6675
Practice Address - Street 1:9127 W RUSSELL RD STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148
Practice Address - Country:US
Practice Address - Phone:702-878-0070
Practice Address - Fax:702-209-2064
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8891319-4406367500000X
NVCRNA000536367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1659889327Medicaid