Basic Information
| Provider Information | |||||||||
| NPI: | 1003015447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARNHAM | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 NE GLEN OAK AVE | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615373167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096248818 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 530 NE GLEN OAK AVE | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615373167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096248818 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209006653 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 809840 | 01 | IL | MEDICARE GROUP NUMBER | OTHER |