Healthcare Provider Details

I. General information

NPI: 1700985769
Provider Name (Legal Business Name): MARC TRAVIS LATTA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD SUITE 1E50
NEWARK DE
19718-2200
US

IV. Provider business mailing address

200 HYGEIA DR SUITE 2300
NEWARK DE
19713-2049
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-1980
  • Fax: 302-733-1986
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110001154
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0001013
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-13626
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: