Provider Demographics
NPI:1033589106
Name:THREADGILL, MARSHALL
Entity Type:Individual
Prefix:MR
First Name:MARSHALL
Middle Name:
Last Name:THREADGILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 SW TIMBER LANE LN
Mailing Address - Street 2:
Mailing Address - City:INDIAHOMA
Mailing Address - State:OK
Mailing Address - Zip Code:73552-2730
Mailing Address - Country:US
Mailing Address - Phone:580-246-8301
Mailing Address - Fax:
Practice Address - Street 1:14 SW TIMBER LANE LN
Practice Address - Street 2:
Practice Address - City:INDIAHOMA
Practice Address - State:OK
Practice Address - Zip Code:73552-2730
Practice Address - Country:US
Practice Address - Phone:580-246-8301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX450074163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse