Provider Demographics
NPI:1346797578
Name:MARCHENA, JOHNATHAN CHRISTOPHER
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:CHRISTOPHER
Last Name:MARCHENA
Suffix:
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 1:133 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711-0800
Mailing Address - Country:US
Mailing Address - Phone:570-208-5900
Mailing Address - Fax:
Practice Address - Street 1:133 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0800
Practice Address - Country:US
Practice Address - Phone:570-208-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA30 828 465390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA$$$$$$$$$OtherATHLETIC TRAINING STUDENT