MEDICARE: MS. MARY LYNN MARSH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	361900	CO
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	C01900	CO

General Provider Information

NPI Number	:	1578542981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY LYNN MARSH PA-C

Provider Business Mailing Address
First Line	:	823 CRESTA ROAD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906
Country	:	US
Telephone Number	:	719-216-7756
Fax Number	:	719-526-7732

Provider Business Practice Location Address
First Line	:	1853 OCONNELL BLVD
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4055
Country	:	US
Telephone Number	:	719-524-5577
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2006
Last Update Date	:	12/04/2020

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