Provider Demographics
NPI:1063597136
Name:PARKINSON, MARTI KRISTA DAVIS (PA-C)
Entity type:Individual
Prefix:MS
First Name:MARTI
Middle Name:KRISTA DAVIS
Last Name:PARKINSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1374 E BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-5420
Mailing Address - Country:US
Mailing Address - Phone:309-453-7390
Mailing Address - Fax:
Practice Address - Street 1:890 W ELLIOT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-5102
Practice Address - Country:US
Practice Address - Phone:480-545-1413
Practice Address - Fax:480-545-1434
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002850363A00000X
AZ4420363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$OtherTRICARE
ILK33496Medicare PIN
IL$$$$$$$$$OtherTRICARE