Provider Demographics
NPI:1386812857
Name:MARTO, MARJORIE TROTTER (PA)
Entity type:Individual
Prefix:MRS
First Name:MARJORIE
Middle Name:TROTTER
Last Name:MARTO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MARJORIE
Other - Middle Name:JEAN
Other - Last Name:TROTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:450 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5450
Mailing Address - Country:US
Mailing Address - Phone:617-632-6140
Mailing Address - Fax:617-632-5168
Practice Address - Street 1:450 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5450
Practice Address - Country:US
Practice Address - Phone:617-632-6140
Practice Address - Fax:617-632-5168
Is Sole Proprietor?:No
Enumeration Date:2008-02-18
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2405OtherSTATE LICENSE