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Master_id

Recent Photo Image:

Last Name:

First Name:

Middle Name:

Suffix:

Title :

Alias Yes/No:

Alias Names Used From To:

Professional Title:

Professional Title Other:

Medical Specialty:

Medical Sub Specialty:

Email Address:

Residence Mailing Address:

Residence Mailing Address Continued:

Residence City:

Residence State:

Residence Zip Code:

Residence Phone Number:

Cell Phone Number:

Residence Fax Number:

Gender:

US Citizen Yes/No:

Date Birth:

City of Birth:

State/Provence of Birth:

Social Security Number:

Marital Status:

Spouse/Emergency Contact:

Emergency Contact Number:

Languages spoken in addition to English:

Languages Other:

Visa Type:

Visa Status:

Visa Number:

Visa Expiration Date:

Passport Number:

Passport Expiration Date:

Passprot Country of Issue:

USMLE Number:

UPIN_No

NPI:

CAQH Provider ID:

FNIN

FNIN_ISSUE

Medicare Number:

Medicaid Number:

Medicaid State:

Workers Compensation Number:

ECFMG Certification:

ECFMG Date Issued:

ECFMG Serial Number:

DEA

DEA_Original_Date

DEA_Exp_Date

Prescriptive Authority:

Prescriptive Issued Date:

CDS

CDS_Original_Date

CDS_Exp_Date

CDS_State

ACLS:

ACLS Issue Date:

ACLS Expiration Date:

ATLS

ATLS_Issue_Date

ATLS_Expiration_Date

BLS

BLS_Issue_Date

BLS_Expiration_Date

NALS

NALS_Issue_Date

NALS_Expiration_Date

PALS xxxx

PALS_Issue_Date

PALS_Expiration_Date

Timmie Scott Parker from 10/21/1946 to April 15, 1994.

Gi, Tumor & Endocrine Surgery

tim_s_parker@yahoo.com

4103 E. 105th Ave

Stella M. Parker

American Sign Language, English

Timmie Scott Parker from 10/21/1946 to April 15, 1994.

Gi, Tumor & Endocrine Surgery

tim_s_parker@yahoo.com

4103 E. 105th Ave

Stella M. Parker

American Sign Language, English

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Master_id
Recent Photo Image:	Upload new file
Last Name:
First Name:
Middle Name:
Suffix:
Title :
Alias Yes/No:
Alias Names Used From To:
Professional Title:
Professional Title Other:
Medical Specialty:
Medical Sub Specialty:
Email Address:
Residence Mailing Address:
Residence Mailing Address Continued:
Residence City:
Residence State:
Residence Zip Code:
Residence Phone Number:
Cell Phone Number:
Residence Fax Number:
Gender:
US Citizen Yes/No:
Date Birth:	/ /
City of Birth:
State/Provence of Birth:
Social Security Number:
Marital Status:
Spouse/Emergency Contact:
Emergency Contact Number:
Languages spoken in addition to English:	Hold CTRL key to select multiple items from the above list.
Languages Other:
Visa Type:
Visa Status:
Visa Number:
Visa Expiration Date:	/ /
Passport Number:
Passport Expiration Date:	/ /
Passprot Country of Issue:
USMLE Number:
UPIN_No
NPI:
CAQH Provider ID:
FNIN
FNIN_ISSUE
Medicare Number:
Medicaid Number:
Medicaid State:
Workers Compensation Number:
ECFMG Certification:
ECFMG Date Issued:	/ /
ECFMG Serial Number:
DEA
DEA_Original_Date	/ /
DEA_Exp_Date	/ /
Prescriptive Authority:
Prescriptive Issued Date:	/ /
CDS
CDS_Original_Date	/ /
CDS_Exp_Date	/ /
CDS_State
ACLS:
ACLS Issue Date:	/ /
ACLS Expiration Date:	/ /
ATLS
ATLS_Issue_Date	/ /
ATLS_Expiration_Date	/ /
BLS
BLS_Issue_Date	/ /
BLS_Expiration_Date	/ /
NALS
NALS_Issue_Date	/ /
NALS_Expiration_Date	/ /
PALS xxxx
PALS_Issue_Date	/ /
PALS_Expiration_Date	/ /