Provider Demographics
NPI:1821184722
Name:MEMMOTT, MARION WILSON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARION
Middle Name:WILSON
Last Name:MEMMOTT
Suffix:
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 1:19208 E APPLEBY RD
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-9063
Mailing Address - Country:US
Mailing Address - Phone:480-313-6413
Mailing Address - Fax:
Practice Address - Street 1:980 E PECOS RD STE 3
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-2438
Practice Address - Country:US
Practice Address - Phone:480-963-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00991Medicare UPIN
AZZ112779Medicare PIN
AZZ112543Medicare PIN