Healthcare Provider Details

I. General information

NPI: 1104903871
Provider Name (Legal Business Name): PAUL J. MARINO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 TOWN CENTER PKWY SUITE 301
RESTON VA
20190-3219
US

IV. Provider business mailing address

2012 SWANS NECK WAY
RESTON VA
20191-4035
US

V. Phone/Fax

Practice location:
  • Phone: 703-709-9701
  • Fax: 703-709-8084
Mailing address:
  • Phone: 703-264-2814
  • Fax: 703-709-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110840218
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0000402
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: