Provider Demographics
NPI:1255402384
Name:PARKS, ROBERT ALLEN (PA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ALLEN
Last Name:PARKS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:298 ANN ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1216
Mailing Address - Country:US
Mailing Address - Phone:248-885-2937
Mailing Address - Fax:
Practice Address - Street 1:6300 22 MILE RD STE 2
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48317-2106
Practice Address - Country:US
Practice Address - Phone:586-726-9860
Practice Address - Fax:586-726-9537
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant