Healthcare Provider Details

I. General information

NPI: 1760480552
Provider Name (Legal Business Name): ERICA NICOLE PARKER P.A.-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ERICA NICOLE MEADOWS

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5480 BIG TYLER RD
CROSS LANES WV
25313-1116
US

IV. Provider business mailing address

5480 BIG TYLER RD
CROSS LANES WV
25313-1116
US

V. Phone/Fax

Practice location:
  • Phone: 304-776-2409
  • Fax: 304-776-2023
Mailing address:
  • Phone: 304-776-2409
  • Fax: 304-776-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number01141
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: