Basic Information
| Provider Information | |||||||||
| NPI: | 1659889327 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARKER | ||||||||
| FirstName: | AMMON | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3570 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841103570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017272056 | ||||||||
| FaxNumber: | 7707016675 | ||||||||
| Practice Location | |||||||||
| Address1: | 9127 W RUSSELL RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028780070 | ||||||||
| FaxNumber: | 7022092064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2018 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 8891319-4406 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | CRNA000536 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1659889327 | 05 | NV | MEDICAID |