Healthcare Provider Details

I. General information

NPI: 1114928165
Provider Name (Legal Business Name): WILLIAM K MARINIS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 10/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 COUNTY ROUTE 47 SUITE 1
SARANAC LAKE NY
12983-5405
US

IV. Provider business mailing address

309 COUNTY ROUTE 47 SUITE 1
SARANAC LAKE NY
12983-5405
US

V. Phone/Fax

Practice location:
  • Phone: 518-891-2688
  • Fax: 518-891-4120
Mailing address:
  • Phone: 518-891-2688
  • Fax: 518-891-4120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004181
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: