Healthcare Provider Details

I. General information

NPI: 1518874718
Provider Name (Legal Business Name): ETHAN PARKS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6312 ALLEN RD
VANCLEAVE MS
39565-8643
US

IV. Provider business mailing address

13323 JOHN CLARK RD
GULFPORT MS
39503-4846
US

V. Phone/Fax

Practice location:
  • Phone: 228-900-0797
  • Fax:
Mailing address:
  • Phone: 228-669-9854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number925860
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: