Provider Demographics
NPI:1497866263
Name:MARVIN, TIMOTHY ANDREW (LSA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:ANDREW
Last Name:MARVIN
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 ROCK HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642-6305
Mailing Address - Country:US
Mailing Address - Phone:512-656-2928
Mailing Address - Fax:512-656-2928
Practice Address - Street 1:171 ROCK HOUSE DR
Practice Address - Street 2:
Practice Address - City:LIBERTY HILL
Practice Address - State:TX
Practice Address - Zip Code:78642-6305
Practice Address - Country:US
Practice Address - Phone:512-656-2928
Practice Address - Fax:512-656-2928
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00018246ZC0007X, 246ZS0410X
COF01177246ZC0007X, 246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF01177OtherCERIFIED FIRST ASSISTANT
TXSA00018OtherLICENSE SURGICAL ASSISTANT