Basic Information
| Provider Information | |||||||||
| NPI: | 1972022853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARINO | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAY | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4040 EMBASSY PKWY STE 400 | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443338341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305764295 | ||||||||
| FaxNumber: | 3305760468 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 E MARKET ST | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2017 | ||||||||
| LastUpdateDate: | 10/24/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.