Provider Demographics
NPI:1174683775
Name:MARSHALL, KATHRYN RENEE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:KATHRYN
Middle Name:RENEE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10623 S REDWOOD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-2481
Mailing Address - Country:US
Mailing Address - Phone:801-566-4242
Mailing Address - Fax:
Practice Address - Street 1:10623 S REDWOOD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-2481
Practice Address - Country:US
Practice Address - Phone:801-566-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002238363AM0700X
UT10142002-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant