Provider Demographics
NPI:1689719932
Name:MARSALA, THOMAS JR (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MARSALA
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-4414
Mailing Address - Country:US
Mailing Address - Phone:318-325-2610
Mailing Address - Fax:318-325-7715
Practice Address - Street 1:1804 N 7TH ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-4414
Practice Address - Country:US
Practice Address - Phone:318-325-2610
Practice Address - Fax:318-325-7715
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10448363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1590720Medicaid
LA5C025P663Medicare ID - Type Unspecified
LA1590720Medicaid