Healthcare Provider Details

I. General information

NPI: 1497416903
Provider Name (Legal Business Name): COLTON PARKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 OCEAN DR STE 8
BOYNTON BEACH FL
33426-5131
US

IV. Provider business mailing address

1023 WATER TOWER WAY APT 207
HYPOLUXO FL
33462-6246
US

V. Phone/Fax

Practice location:
  • Phone: 561-737-4777
  • Fax:
Mailing address:
  • Phone: 772-713-7404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAT9115419
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: