Healthcare Provider Details

I. General information

NPI: 1912231861
Provider Name (Legal Business Name): STACY LYNNE PARKER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 W SLAUGHTER LN STE 185
AUSTIN TX
78748-5992
US

IV. Provider business mailing address

277 BUDDY GANEM DR STE A
PORTLAND TX
78374-3202
US

V. Phone/Fax

Practice location:
  • Phone: 512-647-6049
  • Fax: 361-413-0274
Mailing address:
  • Phone: 361-777-3900
  • Fax: 361-413-0274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA06892
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: