Basic Information
| Provider Information | |||||||||
| NPI: | 1912231861 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARKER | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 277 BUDDY GANEM DR STE A | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783743202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617773900 | ||||||||
| FaxNumber: | 3614130274 | ||||||||
| Practice Location | |||||||||
| Address1: | 2110 W SLAUGHTER LN STE 185 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787485992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5126476049 | ||||||||
| FaxNumber: | 3614130274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2009 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA06892 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.