Basic Information
| Provider Information | |||||||||
| NPI: | 1578542981 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARSH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 823 CRESTA ROAD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192167756 | ||||||||
| FaxNumber: | 7195267732 | ||||||||
| Practice Location | |||||||||
| Address1: | 1853 OCONNELL BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195245577 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 361900 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363LP0808X | C01900 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.