Provider Demographics
NPI:1548318223
Name:PARKER, DEREK JOHN WILLIAM (PA-C)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:JOHN WILLIAM
Last Name:PARKER
Suffix:
Gender:M
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:10630 CLEMSON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-4546
Practice Address - Country:US
Practice Address - Phone:864-482-6000
Practice Address - Fax:864-482-7000
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1057877 NCCPA363A00000X
SC1839363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1544PAMedicaid
SC1544PAMedicaid