Basic Information
| Provider Information | |||||||||
| NPI: | 1255483913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARKS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18700 N 64TH DR | ||||||||
| Address2: | STE 301 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853087109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235615437 | ||||||||
| FaxNumber: | 6235612316 | ||||||||
| Practice Location | |||||||||
| Address1: | 18700 N 64TH DR | ||||||||
| Address2: | 301 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853087109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235615437 | ||||||||
| FaxNumber: | 6235619320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 03/29/2012 | ||||||||
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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 | 363A00000X | 3489 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 161011 | 05 | AZ | MEDICAID |