Provider Demographics
NPI:1033103981
Name:MARQUARDT, TOSHA A (PA-C)
Entity Type:Individual
Prefix:
First Name:TOSHA
Middle Name:A
Last Name:MARQUARDT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TOSHA
Other - Middle Name:A
Other - Last Name:HAMNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:200 TARPON TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5287
Mailing Address - Country:US
Mailing Address - Phone:910-938-1114
Mailing Address - Fax:910-938-1118
Practice Address - Street 1:200 TARPON TRL
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5287
Practice Address - Country:US
Practice Address - Phone:910-938-1114
Practice Address - Fax:910-938-1118
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA031363A00000X
OK2238363A00000X
CO4572363A00000X
TN3180363A00000X
NC363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06377709Medicaid
OK200502800AMedicaid
1033103981OtherNPI
MSS41828Medicare UPIN