Provider Demographics
NPI:1639450778
Name:MARCHIOLI, MARC EDWARD (PA)
Entity type:Individual
Prefix:MR
First Name:MARC
Middle Name:EDWARD
Last Name:MARCHIOLI
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 1:410 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4203
Mailing Address - Country:US
Mailing Address - Phone:407-303-7283
Mailing Address - Fax:407-303-0473
Practice Address - Street 1:410 S 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4203
Practice Address - Country:US
Practice Address - Phone:407-303-7283
Practice Address - Fax:407-303-0473
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA965207RC0200X, 208M00000X
MAPA-TF-0188363A00000X
KYPA3370363A00000X
MI5601010961363A00000X
VA0110010754363A00000X
IL085009455363A00000X
NY023516363AM0700X
PAMA055058363AM0700X
NMPA2023-0208363AM0700X
FLPA9106961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA965OtherGA STATE LICENSE
KY7100961270Medicaid
PAMA055058OtherPA STATE LICENSE
NMPA2023-0208OtherNM LICENSE
KYPA3370OtherSTATE LICENSE
FLPA9106961OtherFL STATE LICENSE