Basic Information
| Provider Information | |||||||||
| NPI: | 1417508946 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARKER | ||||||||
| FirstName: | DEVIN | ||||||||
| MiddleName: | VERONICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2799 ROUTE 112 STE 7&11 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117632535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317325222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2799 ROUTE 112 STE 7&11 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117632535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317325222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2019 | ||||||||
| LastUpdateDate: | 01/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 383214 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1417508946 | 05 | NY | MEDICAID |