Healthcare Provider Details

I. General information

NPI: 1417404484
Provider Name (Legal Business Name): MATTHEW MARSH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 WINROW AVE USA MEDDAC, RWBAHC
FORT HUACHUCA AZ
85613
US

IV. Provider business mailing address

2240 WINROW AVE USA MEDDAC, RWBAHC
FORT HUACHUCA AZ
85613
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-9026
  • Fax:
Mailing address:
  • Phone: 520-533-9026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number13-91206-071
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: