Provider Demographics
NPI:1639522766
Name:MARSHALL, OLIVIA MARIE (PA)
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:MARIE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:OLIVIA
Other - Middle Name:MARIE
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:399 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4815
Mailing Address - Country:US
Mailing Address - Phone:909-882-5867
Mailing Address - Fax:909-803-1923
Practice Address - Street 1:900 E WASHINGTON ST STE 200
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4192
Practice Address - Country:US
Practice Address - Phone:909-882-5867
Practice Address - Fax:909-503-1913
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55316363A00000X
390200000X
AZ6570363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program