Provider Demographics
NPI:1952854721
Name:MARSHALL, BRENT THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:THOMAS
Last Name:MARSHALL
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 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1613
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:907-399-1717
Practice Address - Street 1:11701-32 SAN JOSE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-0756
Practice Address - Country:US
Practice Address - Phone:904-880-0911
Practice Address - Fax:904-880-9388
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9109612363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant