Provider Demographics
NPI:1740233006
Name:MARSHALL, MARK DUANE (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DUANE
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:200 ELM ST N
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-7901
Mailing Address - Country:US
Mailing Address - Phone:320-532-3154
Mailing Address - Fax:320-532-3111
Practice Address - Street 1:200 ELM ST N
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-7901
Practice Address - Country:US
Practice Address - Phone:320-532-3154
Practice Address - Fax:320-532-3111
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8937363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-17254OtherMEDICA ONAMIA
MN520T3MAOtherBLUE CROSS HOSPITAL
MN520T2MAOtherBLUE CROSS CLINIC
MN745392200Medicaid
MNNA9091011247OtherPREFERRED ONE
MN122391OtherUCARE
MNHP44081OtherHEALTH PARTNERS
MN01-17254OtherMEDICA ONAMIA
MN970002041Medicare ID - Type UnspecifiedONAMIA CLINIC
MN745392200Medicaid
MNHP44081OtherHEALTH PARTNERS