Healthcare Provider Details

I. General information

NPI: 1992386866
Provider Name (Legal Business Name): COURTNEY E PARKS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOCH RAVEN BLVD 3 NORTH
BALTIMORE MD
21239-2945
US

IV. Provider business mailing address

5601 LOCH RAVEN BLVD 3 NORTH
BALTIMORE MD
21239-2945
US

V. Phone/Fax

Practice location:
  • Phone: 443-444-3775
  • Fax: 443-444-4678
Mailing address:
  • Phone: 443-444-3775
  • Fax: 443-444-4678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0007925
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: