MEDICARE: MR. NICHOLAS GENE PARKS RN

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	163WM0705X	Medical-Surgical Registered Nurse	0001247709	VA

General Provider Information

NPI Number	:	1700256211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NICHOLAS GENE PARKS RN

Provider Business Mailing Address
First Line	:	6144 ROLFE AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23508-1026
Country	:	US
Telephone Number	:	757-339-3876
Fax Number	:

Provider Business Practice Location Address
First Line	:	6144 ROLFE AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23508-1026
Country	:	US
Telephone Number	:	757-339-3876
Fax Number	:

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

Provider Enumeration Date	:	09/28/2015
Last Update Date	:	09/28/2015

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