Provider Demographics
NPI:1326195876
Name:HULL, MARC BRYAN (PA)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:BRYAN
Last Name:HULL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1860 RENZULLI RD
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-1726
Mailing Address - Country:US
Mailing Address - Phone:386-663-3061
Mailing Address - Fax:386-663-3066
Practice Address - Street 1:1860 RENZULLI RD
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-1726
Practice Address - Country:US
Practice Address - Phone:386-663-3061
Practice Address - Fax:386-663-3066
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9104001363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA 9104001OtherPA LICENSE