Provider Demographics
NPI:1457522666
Name:PARKER, ROXANNE PAULETTE
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:PAULETTE
Last Name:PARKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 ROSECRANS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-1931
Mailing Address - Country:US
Mailing Address - Phone:619-223-3485
Mailing Address - Fax:
Practice Address - Street 1:6154 MISSION GORGE RD
Practice Address - Street 2:120
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3493
Practice Address - Country:US
Practice Address - Phone:619-285-1718
Practice Address - Fax:619-285-3803
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QR0405X261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37ALMedicaid