Provider Demographics
NPI:1245843143
Name:SICKELTON, MARCUS LEE DAVID (PA)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:LEE DAVID
Last Name:SICKELTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18565 W BASELINE RD APT 508
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-2941
Mailing Address - Country:US
Mailing Address - Phone:805-423-1064
Mailing Address - Fax:
Practice Address - Street 1:400 W PUEBLO ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-4353
Practice Address - Country:US
Practice Address - Phone:805-682-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA201952363A00000X
OR390200000X
CAPA1028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program