Provider Demographics
NPI:1699190942
Name:MARVIN, ALISA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:MARVIN
Suffix:
Gender:F
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 1:303 CHESTNUT COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-9607
Mailing Address - Country:US
Mailing Address - Phone:440-204-7400
Mailing Address - Fax:
Practice Address - Street 1:303 CHESTNUT COMMONS DR
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-9607
Practice Address - Country:US
Practice Address - Phone:440-204-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH004009363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant