Healthcare Provider Details

I. General information

NPI: 1740233006
Provider Name (Legal Business Name): MARK DUANE MARSHALL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ELM ST N
ONAMIA MN
56359-7901
US

IV. Provider business mailing address

200 ELM ST N
ONAMIA MN
56359-7901
US

V. Phone/Fax

Practice location:
  • Phone: 320-532-3154
  • Fax: 320-532-3111
Mailing address:
  • Phone: 320-532-3154
  • Fax: 320-532-3111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8937
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: