Basic Information
| Provider Information | |||||||||
| NPI: | 1669478210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARKER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3777 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 NW 22ND AVE STE 660 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972103083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034137162 | ||||||||
| FaxNumber: | 5034137148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 05/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA00794 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 227036 | 05 | OR | MEDICAID |