Provider Demographics
NPI:1174663991
Name:MARDER, CAROL N (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:N
Last Name:MARDER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E OLNEY AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2421
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-254-2599
Practice Address - Street 1:5401 OLD YORK RD
Practice Address - Street 2:KLEIN 300
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19141-3030
Practice Address - Country:US
Practice Address - Phone:215-456-7190
Practice Address - Fax:215-456-3419
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP006965C363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232664784OtherTIN
PAP72646Medicare UPIN
PA064482EK3Medicare PIN