Provider Demographics
NPI:1538104393
Name:MARRIOTT, MATTHEW (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MARRIOTT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 UPPER CHESAPEAKE DR
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4324
Mailing Address - Country:US
Mailing Address - Phone:443-643-5000
Mailing Address - Fax:433-643-1505
Practice Address - Street 1:500 UPPER CHESAPEAKE DR
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4324
Practice Address - Country:US
Practice Address - Phone:443-643-5000
Practice Address - Fax:433-643-1505
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC01999363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS82674Medicare UPIN