Provider Demographics
NPI:1215995576
Name:MACQUEEN, MARJORIE M (PA)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:M
Last Name:MACQUEEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12469
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2469
Mailing Address - Country:US
Mailing Address - Phone:866-325-0282
Mailing Address - Fax:
Practice Address - Street 1:2450 ASHBY AVENUE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2067
Practice Address - Country:US
Practice Address - Phone:510-204-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17161207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17161Medicaid
CA1215995576Medicaid
CA0PA171610Medicare ID - Type Unspecified
Q09227Medicare UPIN
CA1215995576Medicaid