Basic Information
| Provider Information | |||||||||
| NPI: | 1578808424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARBAN | ||||||||
| FirstName: | HIAWATHA | ||||||||
| MiddleName: | DAVID | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1270 E EDGEWOOD ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658043615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105930811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1235 E CHEROKEE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658042203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178202000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2012 | ||||||||
| LastUpdateDate: | 12/04/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 2010007775 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.