Provider Demographics
NPI:1104243500
Name:MITCHELL, MARSHAWN SR
Entity type:Individual
Prefix:
First Name:MARSHAWN
Middle Name:
Last Name:MITCHELL
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23605 W BOWKER ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-7217
Mailing Address - Country:US
Mailing Address - Phone:757-763-0754
Mailing Address - Fax:
Practice Address - Street 1:23605 W BOWKER ST
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-7217
Practice Address - Country:US
Practice Address - Phone:757-763-0754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center