Provider Demographics
NPI:1770503203
Name:STOLL, MARC (PA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:STOLL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 CLEVELAND AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7180
Mailing Address - Country:US
Mailing Address - Phone:239-936-6778
Mailing Address - Fax:
Practice Address - Street 1:3210 CLEVELAND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7180
Practice Address - Country:US
Practice Address - Phone:239-936-6778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100946363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0664623OtherAETNA HMO
FL2416393001OtherCIGNA
FL4198735OtherAETNA PPO
FL6100549OtherGHI
FL80505OtherBCBS
FL0905257OtherUHC
FL6100549OtherGHI
FL4198735OtherAETNA PPO
FLE3011ZMedicare PIN