Provider Demographics
NPI:1184746026
Name:PARKS, KELLY POTTER (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:POTTER
Last Name:PARKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7817 GRACE CIR
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-4337
Mailing Address - Country:US
Mailing Address - Phone:302-628-3229
Mailing Address - Fax:
Practice Address - Street 1:121 S FRONT ST
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-3511
Practice Address - Country:US
Practice Address - Phone:302-629-5030
Practice Address - Fax:302-629-5035
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000165363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC5-0000165OtherSTATE LICENSE NUMBER
DERXPA02015OtherSTATE PRESCRIPTION NUMBER