Basic Information
| Provider Information | |||||||||
| NPI: | 1598712986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARROQUIN | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664541 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 12/14/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00273 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1407812365 | 01 | OR | NBMC MAIN GROUP NPI NUMBER | OTHER | 161133 | 01 | OR | NBMC MAIN GROUP DMAP NUMBER | OTHER | 050922005 | 01 | OR | BLUE CROSS | OTHER | 970002408 | 01 | OR | RAIL ROAD MEDICARE | OTHER | C105010 | 01 | OR | PACIFIC SOURCE | OTHER | MD16946 | 01 | OR | SUPERVISING PHYSICIAN OR LICENSE- DR. RICHARD JANY | OTHER | 93-0635514 | 01 | NBMC MAIN GROUP TAX ID FOR BILLING | OTHER | R0000WFBTV | 01 | OR | NBMC MAIN - GROUP MEDICARE NUMBER | OTHER | 97420A003 | 01 | OR | TRICARE | OTHER |