Provider Demographics
NPI:1437176443
Name:RECKER, MARILYN ANGELA (PAC)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:ANGELA
Last Name:RECKER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7950 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-435-7211
Mailing Address - Fax:260-435-7211
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-7211
Practice Address - Fax:260-435-7211
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000383363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000639294OtherBC/BS
INP00775307OtherRAILROAD MEDICARE
IN000000659918OtherBC/BS
IN138420UUMedicare ID - Type Unspecified
IN000000639294OtherBC/BS
IN265520KMedicare PIN
IN261920EEMedicare PIN
INP00775307OtherRAILROAD MEDICARE
IN178650JJMedicare ID - Type Unspecified