Provider Demographics
NPI:1306882881
Name:SOUTHWELL, MARCY G (PA C)
Entity type:Individual
Prefix:MRS
First Name:MARCY
Middle Name:G
Last Name:SOUTHWELL
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
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Mailing Address - Street 1:60 COMMERCIAL ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-5071
Mailing Address - Country:US
Mailing Address - Phone:603-228-1763
Mailing Address - Fax:603-228-7088
Practice Address - Street 1:60 COMMERCIAL ST
Practice Address - Street 2:SUITE 404
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-5071
Practice Address - Country:US
Practice Address - Phone:603-228-1763
Practice Address - Fax:603-228-7088
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-12-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NH0391P363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30332153Medicaid
AP1727Medicare ID - Type Unspecified
NH30332153Medicaid