Provider Demographics
NPI:1992801179
Name:MARR, WILLIAM LEWIS IV (PA-C)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:LEWIS
Last Name:MARR
Suffix:IV
Gender:
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:PO BOX 802793
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2793
Mailing Address - Country:US
Mailing Address - Phone:800-953-0104
Mailing Address - Fax:
Practice Address - Street 1:810 E 3RD ST UNIT 201
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5759
Practice Address - Country:US
Practice Address - Phone:970-764-1790
Practice Address - Fax:970-375-7927
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01678363A00000X
COPA.0008209363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA01678OtherPA STATE LICENSE