Healthcare Provider Details

I. General information

NPI: 1912826363
Provider Name (Legal Business Name): MR. ETHAN CHRISTOPHER PARKER SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10625 SE 362ND AVE UNIT B4
BORING OR
97009-9741
US

IV. Provider business mailing address

10625 SE 362ND AVE UNIT B4
BORING OR
97009-9741
US

V. Phone/Fax

Practice location:
  • Phone: 971-314-2900
  • Fax:
Mailing address:
  • Phone: 971-314-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: