Provider Demographics
NPI:1477687952
Name:MARCOUX, KELLY J (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:MARCOUX
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:BAYNE-JONES ARMY COMMUNITY HOSPITAL
Mailing Address - Street 2:1585 THIRD ST
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459
Mailing Address - Country:US
Mailing Address - Phone:337-531-0297
Mailing Address - Fax:
Practice Address - Street 1:BAYNE-JONES ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:1585 THIRD ST
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459
Practice Address - Country:US
Practice Address - Phone:337-531-0297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-1252363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS99226Medicare UPIN
OHMAPA15031Medicare ID - Type Unspecified