Healthcare Provider Details

I. General information

NPI: 1083957070
Provider Name (Legal Business Name): CATHLEEN E MARSHALL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 E MERIDIAN PARK LOOP STE 200
WASILLA AK
99654-7242
US

IV. Provider business mailing address

PO BOX 4105
PORTLAND OR
97208-4105
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-4400
  • Fax: 907-357-4533
Mailing address:
  • Phone: 866-907-1068
  • Fax: 425-917-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number163531
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number163531
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number163531
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier777714100
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer
# 2
Identifier1711197
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: