Provider Demographics
NPI:1821741711
Name:THOMASRUFUS, MARQUETTE SHANTEE
Entity Type:Individual
Prefix:
First Name:MARQUETTE
Middle Name:SHANTEE
Last Name:THOMASRUFUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 E PARKERVILLE RD STE A8
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-6420
Mailing Address - Country:US
Mailing Address - Phone:469-747-3155
Mailing Address - Fax:800-517-4729
Practice Address - Street 1:1301 E PARKERVILLE RD STE A8
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-6420
Practice Address - Country:US
Practice Address - Phone:469-747-3155
Practice Address - Fax:800-517-4729
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 172A00000X, 172V00000X, 246QL0900X, 246RP1900X, 374U00000X
TX115570247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No171W00000XOther Service ProvidersContractor
No172A00000XOther Service ProvidersDriver
No172V00000XOther Service ProvidersCommunity Health Worker
No246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2247456OtherCLIA LABORATORY