Provider Demographics
NPI:1679591937
Name:MARSHALL, GREGORY ROBERT JR (LPN)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ROBERT
Last Name:MARSHALL
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1561 PIUTE ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-5554
Mailing Address - Country:US
Mailing Address - Phone:760-561-1150
Mailing Address - Fax:
Practice Address - Street 1:USA MEDDAC
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-380-3144
Practice Address - Fax:760-380-3298
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP39419164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse