Provider Demographics
NPI:1104903871
Name:MARINO, PAUL J (PA-C)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:MARINO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 SWANS NECK WAY
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-4035
Mailing Address - Country:US
Mailing Address - Phone:703-264-2814
Mailing Address - Fax:703-709-8084
Practice Address - Street 1:1850 TOWN CENTER PKWY
Practice Address - Street 2:SUITE 301
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3219
Practice Address - Country:US
Practice Address - Phone:703-709-9701
Practice Address - Fax:703-709-8084
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840218363AS0400X
MDC0000402363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R23265Medicare UPIN
001442P08Medicare ID - Type Unspecified