Provider Demographics
NPI:1891199311
Name:SIDDLE, MARIE KOENIG (PA-C)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:KOENIG
Last Name:SIDDLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:MICHELLE
Other - Last Name:KOENIG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 7527
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-0727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1030 REFUGEE RD STE 280
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-0019
Practice Address - Country:US
Practice Address - Phone:614-788-4390
Practice Address - Fax:614-788-4399
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2024-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH004108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant