Provider Demographics
NPI:1770733560
Name:MARSH, MARIAN M (PA-C)
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:M
Last Name:MARSH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIAN
Other - Middle Name:M
Other - Last Name:BATTER CADE CORTEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3340 EAST GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1075 N CURTIS RD
Practice Address - Street 2:STE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1350
Practice Address - Country:US
Practice Address - Phone:208-367-8333
Practice Address - Fax:208-367-2003
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10511363A00000X
IDPA-853363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNENROLLEDMedicaid
MN970003769Medicare PIN