Provider Demographics
NPI:1235449638
Name:SCHMIDT, MARLIE DANA (PA)
Entity Type:Individual
Prefix:
First Name:MARLIE
Middle Name:DANA
Last Name:SCHMIDT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 HAYNES ST
Mailing Address - Street 2:EASTERN CONNECTICUT HEALTH NETWORK
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4131
Mailing Address - Country:US
Mailing Address - Phone:860-647-6475
Mailing Address - Fax:
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:EASTERN CONNECTICUT HEALTH NETWORK
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-647-6475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0049093363AM0700X
CT002418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003024189Medicaid
CT003024189Medicaid