Provider Demographics
NPI:1922095173
Name:MARSHALL, GENA WILLARD (PA-C)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:WILLARD
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GENA
Other - Middle Name:
Other - Last Name:WILLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9101 NORTH CENTRAL EXPRESSWAY
Mailing Address - Street 2:SUITE 600
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9101 N CENTRAL EXPY STE 600
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5956
Practice Address - Country:US
Practice Address - Phone:214-818-0935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03192363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206246501Medicaid
TX8376NDOtherBLUE CROSS BLUE SHIELD
TX1922095173OtherBLUE CROSS BLUE SHIELD
TXP01107875OtherRR MEDICARE
TX206246502Medicaid
TX8Y8690OtherBLUE CROSS BLUE SHIELD
TXP00735961OtherRAILROAD MEDICARE
TX206246504Medicaid
TXP01259383OtherMEDICARE RR
TX864N28OtherBCBS
TX206246503Medicaid
TXTXB151190Medicare PIN
TX8L15275Medicare PIN
TX8Y8690OtherBLUE CROSS BLUE SHIELD
TX864N28OtherBCBS
TX8376NDOtherBLUE CROSS BLUE SHIELD
8A2257Medicare ID - Type Unspecified
TX206246501Medicaid