Provider Demographics
NPI:1902073208
Name:MARSHALL FAMILY PRACTICE CLINIC, PLLC
Entity Type:Organization
Organization Name:MARSHALL FAMILY PRACTICE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:936-257-1102
Mailing Address - Street 1:601 S WINFREE ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TX
Mailing Address - Zip Code:77535-2945
Mailing Address - Country:US
Mailing Address - Phone:936-257-1102
Mailing Address - Fax:936-257-1109
Practice Address - Street 1:601 S WINFREE ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TX
Practice Address - Zip Code:77535-2945
Practice Address - Country:US
Practice Address - Phone:936-257-1102
Practice Address - Fax:936-257-1109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX509147363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXNP0425Medicare PIN
TXQ08787Medicare UPIN