Healthcare Provider Details

I. General information

NPI: 1093045668
Provider Name (Legal Business Name): MARION VIRGIL SANDERS IV PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 STATE AVE STE 100
PANAMA CITY FL
32405-3942
US

IV. Provider business mailing address

2401 STATE AVE STE 100
PANAMA CITY FL
32405-3942
US

V. Phone/Fax

Practice location:
  • Phone: 850-628-9177
  • Fax:
Mailing address:
  • Phone: 850-628-9177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: