Provider Demographics
NPI:1609457894
Name:MARSHALL, ETHAN ZACHARY (CPO)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:ZACHARY
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 315
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75030-0315
Mailing Address - Country:US
Mailing Address - Phone:214-501-4050
Mailing Address - Fax:214-501-4640
Practice Address - Street 1:9400 LAKEVIEW PKWY STE 121
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4401
Practice Address - Country:US
Practice Address - Phone:214-501-4050
Practice Address - Fax:214-501-4640
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2120224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist