Basic Information
| Provider Information | |||||||||
| NPI: | 1235187105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARKER | ||||||||
| FirstName: | DARRELL | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2825 HUNTERS TRL | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539013429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087427161 | ||||||||
| FaxNumber: | 6084753060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2825 HUNTERS TRL | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539013429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087427161 | ||||||||
| FaxNumber: | 6087253060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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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 | 363A00000X | 76-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1022697 | 01 | WI | PHYSICIANS PLUS | OTHER | 5878 | 01 | WI | DEAN HEALTH INSURANCE | OTHER | 42967300 | 05 | WI | MEDICAID |