Provider Demographics
NPI:1124303334
Name:ORTIZ, MARCUS RENE JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:RENE
Last Name:ORTIZ
Suffix:JR
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 1:1450 DOWELL SPRINGS BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2448
Mailing Address - Country:US
Mailing Address - Phone:865-524-2547
Mailing Address - Fax:865-205-5601
Practice Address - Street 1:1450 DOWELL SPRINGS BLVD STE 210
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2448
Practice Address - Country:US
Practice Address - Phone:865-524-2547
Practice Address - Fax:865-205-5601
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21940207N00000X, 363AM0700X
TNPA3923363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ050882Medicaid