Provider Demographics
NPI:1962436584
Name:MARSHALL, MOLLY (PA-C)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:F
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 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:2122 HEALTH DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9698
Practice Address - Country:US
Practice Address - Phone:616-252-7494
Practice Address - Fax:616-252-7830
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001725363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601007259OtherSTATE LICENSE NUMBER
MI5601007259OtherSTATE LICENSE NUMBER