Provider Demographics
NPI:1700048790
Name:PARKER, ANDREA SHANNON (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:SHANNON
Last Name:PARKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 3RD ST
Mailing Address - Street 2:APT 2
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2727
Mailing Address - Country:US
Mailing Address - Phone:317-417-1114
Mailing Address - Fax:
Practice Address - Street 1:220 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-3515
Practice Address - Country:US
Practice Address - Phone:401-849-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11014450A390200000X
390200000X
RIMD14355208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program