Provider Demographics
NPI:1669039798
Name:PARKER, COY DYLAN (INDEPENDENT DUTY COR)
Entity Type:Individual
Prefix:
First Name:COY
Middle Name:DYLAN
Last Name:PARKER
Suffix:
Gender:M
Credentials:INDEPENDENT DUTY COR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11439 MADERA ROSA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124
Mailing Address - Country:US
Mailing Address - Phone:949-295-8153
Mailing Address - Fax:
Practice Address - Street 1:SURFACE WARFARE MEDICAL INSTITUTE
Practice Address - Street 2:34101 FARENHOLT AVE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134
Practice Address - Country:US
Practice Address - Phone:619-532-6659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman