Healthcare Provider Details

I. General information

NPI: 1356758528
Provider Name (Legal Business Name): MARCUS ETIENNE CNIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2014
Last Update Date: 05/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9432 WELLSTONE DR
LAND O LAKES FL
34638-2574
US

IV. Provider business mailing address

9432 WELLSTONE DR
LAND O LAKES FL
34638-2574
US

V. Phone/Fax

Practice location:
  • Phone: 225-773-6763
  • Fax:
Mailing address:
  • Phone: 225-773-6763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number2701
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: