Provider Demographics
NPI:1912478231
Name:PARKER, RYAN (NP-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PARKER
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6812 STATE ROUTE 162 STE 202
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8562
Mailing Address - Country:US
Mailing Address - Phone:217-313-6566
Mailing Address - Fax:
Practice Address - Street 1:6812 STATE ROUTE 162 STE 202
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8562
Practice Address - Country:US
Practice Address - Phone:618-288-6844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-14
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018533363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily