Healthcare Provider Details

I. General information

NPI: 1730417262
Provider Name (Legal Business Name): CARMELLA CHARMAYNE MARSHALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 10/27/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 DENBIGH BLVD
NEWPORT NEWS VA
23608-4415
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 757-283-8300
  • Fax: 910-323-3951
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003117
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0004211
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-05753
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: