Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TH0100X | Health Service | PYR0055 | MO |
NPI | 1346205630 |
---|---|
Provider Name | Jerry Parker |
First Address | Columbia, MO 65201-5275 |
Second Address | Columbia, MO 65201-5275 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2006 |
Last Update Date | 08/07/2007 |