Provider Demographics
NPI:1932606712
Name:MARSHALL, TY DANIEL (PA-C)
Entity type:Individual
Prefix:
First Name:TY
Middle Name:DANIEL
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 QUARRY ST APT 812
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4154
Mailing Address - Country:US
Mailing Address - Phone:847-477-2168
Mailing Address - Fax:
Practice Address - Street 1:290 QUARRY ST APT 812
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4154
Practice Address - Country:US
Practice Address - Phone:847-477-2168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty