Provider Demographics
NPI:1083873541
Name:COTTEN, MARVIN (PA)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:COTTEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:706 W KING ST
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-2708
Practice Address - Country:US
Practice Address - Phone:980-487-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06861363A00000X
NC221411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2807PAMedicaid
NC1083873541Medicaid
NC1083873541Medicaid
NCNCW141AMedicare PIN