Provider Demographics
NPI:1568059004
Name:SHATTUCK, MARNEY BLAKE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARNEY
Middle Name:BLAKE
Last Name:SHATTUCK
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 1:360 US HIGHWAY 1 BYP UNIT 102
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7105
Mailing Address - Country:US
Mailing Address - Phone:603-410-6700
Mailing Address - Fax:603-319-8308
Practice Address - Street 1:139 TURNPIKE RD
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-2835
Practice Address - Country:US
Practice Address - Phone:508-882-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA8569363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110183157AMedicaid