Healthcare Provider Details

I. General information

NPI: 1760747844
Provider Name (Legal Business Name): STEPHANIE M PARKS DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WALTER ST NE STE 510A
ALBUQUERQUE NM
87102-2534
US

IV. Provider business mailing address

500 WALTER ST NE STE 510A
ALBUQUERQUE NM
87102-2534
US

V. Phone/Fax

Practice location:
  • Phone: 505-404-9922
  • Fax:
Mailing address:
  • Phone: 55-404-9922
  • Fax: 949-404-6689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPDT-529
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: