Provider Demographics
NPI:1619973930
Name:MARCUM, KELLY (NP)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:
Last Name:MARCUM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:2200 E SHOW LOW LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901
Mailing Address - Country:US
Mailing Address - Phone:928-537-6978
Mailing Address - Fax:928-537-4205
Practice Address - Street 1:2931 S HWY 260
Practice Address - Street 2:
Practice Address - City:OVERGAARD
Practice Address - State:AZ
Practice Address - Zip Code:85933
Practice Address - Country:US
Practice Address - Phone:928-536-3616
Practice Address - Fax:928-536-3615
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZRN036514363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZQ49838Medicare UPIN