Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | 23890 | MN |
N | 208000000X | Pediatrician | 23890 | MN |
NPI | 1164448114 |
---|---|
Provider Name | Jay Leslie Parker |
First Address | Duluth, MN 55805-1951 |
Second Address | Duluth, MN 55805-1951 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2006 |
Last Update Date | 05/05/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
30015900 | (05) | WI |
645202700 | (05) | MN |
D75411 | (02) |