Healthcare Provider Details

I. General information

NPI: 1629282074
Provider Name (Legal Business Name): STEPHEN R. PARKER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43219 MITCHELL AVE
MATTAWAN MI
49071-8919
US

IV. Provider business mailing address

900 PEELER ST
KALAMAZOO MI
49008-2380
US

V. Phone/Fax

Practice location:
  • Phone: 616-821-4759
  • Fax:
Mailing address:
  • Phone: 269-345-8618
  • Fax: 269-345-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704242328
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: