Provider Demographics
NPI:1235190596
Name:MARRA, JOSEPH F JR (CRNP)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:F
Last Name:MARRA
Suffix:JR
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NM
Mailing Address - Zip Code:88415-3339
Mailing Address - Country:US
Mailing Address - Phone:814-943-6111
Mailing Address - Fax:914-943-6118
Practice Address - Street 1:400 HARDING ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NM
Practice Address - Zip Code:88415-3339
Practice Address - Country:US
Practice Address - Phone:814-943-6111
Practice Address - Fax:914-943-6118
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007906363LF0000X, 261QU0200X
NMCNP-01916363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA571228130OtherDEVON
PA1015127860001OtherACCESS
PA1813844OtherHIGHMARK PPO
OK200515230AMedicaid
PA57-122813OtherUMWA
PA57-1228130OtherVANTAGE PPO
NM50706756Medicaid
PA571228130OtherTRICARE
Q69576Medicare UPIN
NM50706756Medicaid