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General NPI Number Information
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NPI Number | 1003585399
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Entity Type | Individual
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Provider Name | DESMOND JACOB MARROQUIN
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Gender | Male
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Dates
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Enumeration Date | 09/09/2021
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Last Update Date | 11/26/2024
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Provider Practice Location Address
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Address Line | 420 POLIFKA DR
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City | SHAW AFB
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State | SC
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Zip | 29152-5100
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Country | US
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Telephone | 803-885-0249
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Fax |
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Provider Business Mailing Address
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Address Line | 420 POLIFKA DR
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City | SHAW AFB
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State | SC
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Zip | 29152-5100
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Country | US
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Telephone | 803-885-0249
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1710I1003X
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Taxonomy Name | Independent Duty Medical Technicians
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License Number |
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License Number State |
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