Provider Demographics
NPI:1649219361
Name:SCHULTZ, MARSHA (PA)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3560 PONTIAC LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2337
Mailing Address - Country:US
Mailing Address - Phone:248-674-2259
Mailing Address - Fax:247-674-3356
Practice Address - Street 1:3560 PONTIAC LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2337
Practice Address - Country:US
Practice Address - Phone:248-674-2259
Practice Address - Fax:248-674-3356
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI5601001151146D00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN85240010Medicare PIN
S50916Medicare UPIN
P40540029Medicare PIN
P40010028Medicare PIN