MEDICARE: JASON ALLAN PARKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	LP047167	AZ

General Provider Information

NPI Number	:	1093239816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON ALLAN PARKER

Provider Business Mailing Address
First Line	:	3310 W CHERYL DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-9575
Country	:	US
Telephone Number	:	602-926-7210
Fax Number	:	602-291-9375

Provider Business Practice Location Address
First Line	:	3310 WEST CHERYL DRIVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051
Country	:	US
Telephone Number	:	602-926-7210
Fax Number	:	602-291-9375

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2017
Last Update Date	:	07/21/2022

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