Provider Demographics
NPI:1962459404
Name:PUTNAM, MARSHALL EDWARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARSHALL
Middle Name:EDWARD
Last Name:PUTNAM
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 1:165 RUTH CIR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-4209
Mailing Address - Country:US
Mailing Address - Phone:919-818-4755
Mailing Address - Fax:
Practice Address - Street 1:217 GLENSFORD DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-0892
Practice Address - Country:US
Practice Address - Phone:910-483-4647
Practice Address - Fax:910-483-6431
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103249363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102360Medicaid
NCP54658Medicare UPIN
NC2754804Medicare ID - Type Unspecified