Provider Demographics
NPI:1881014702
Name:KIRCHUBEL, MARILYNN (PA)
Entity Type:Individual
Prefix:
First Name:MARILYNN
Middle Name:
Last Name:KIRCHUBEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 W GRANT LINE RD
Mailing Address - Street 2:STE 230
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-7334
Mailing Address - Country:US
Mailing Address - Phone:209-832-8700
Mailing Address - Fax:209-832-2210
Practice Address - Street 1:2160 W GRANT LINE RD STE 230
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-7334
Practice Address - Country:US
Practice Address - Phone:209-832-8700
Practice Address - Fax:209-832-2210
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 11603363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 11603OtherSTATE OF CALIFORNIA PHYSICIAN ASSISTANT LICENSE