Healthcare Provider Details

I. General information

NPI: 1255917589
Provider Name (Legal Business Name): MS. BRIANNA MARIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 TOD AVE SW
WARREN OH
44485-3608
US

IV. Provider business mailing address

716 TOD AVE SW
WARREN OH
44485-3608
US

V. Phone/Fax

Practice location:
  • Phone: 330-373-0222
  • Fax:
Mailing address:
  • Phone: 330-373-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007256RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: