Provider Demographics
NPI:1992713887
Name:GARRETT, MARIANNE KULESA (PAC)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:KULESA
Last Name:GARRETT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5803 ARMY PENTAGON MF877B
Mailing Address - Street 2:DILORENZO TRICARE HEALTH CLINIC
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20310
Mailing Address - Country:US
Mailing Address - Phone:703-914-8000
Mailing Address - Fax:703-642-1876
Practice Address - Street 1:5803 ARMY PENTAGON MF877B
Practice Address - Street 2:DILORENZO TRICARE HEALTH CLINIC
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20310-0001
Practice Address - Country:US
Practice Address - Phone:703-914-8000
Practice Address - Fax:703-642-1876
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001599363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P72698Medicare UPIN