Provider Demographics
NPI:1598712986
Name:MARROQUIN, JOSE A (PA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:MARROQUIN
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 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4541
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4541
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407812365OtherNBMC MAIN GROUP NPI NUMBER
OR161133OtherNBMC MAIN GROUP DMAP NUMBER
OR050922005OtherBLUE CROSS
OR970002408OtherRAIL ROAD MEDICARE
ORC105010OtherPACIFIC SOURCE
ORMD16946OtherSUPERVISING PHYSICIAN OR LICENSE- DR. RICHARD JANY
93-0635514OtherNBMC MAIN GROUP TAX ID FOR BILLING
ORR0000WFBTVOtherNBMC MAIN - GROUP MEDICARE NUMBER
OR97420A003OtherTRICARE
OR161133OtherNBMC MAIN GROUP DMAP NUMBER
93-0635514OtherNBMC MAIN GROUP TAX ID FOR BILLING