Provider Demographics
NPI:1972883791
Name:MARSOLAN, JAY A (NP)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:A
Last Name:MARSOLAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0711
Mailing Address - Country:US
Mailing Address - Phone:903-831-2426
Mailing Address - Fax:903-793-0496
Practice Address - Street 1:1509 W LOOP 281
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-2820
Practice Address - Country:US
Practice Address - Phone:903-759-9355
Practice Address - Fax:903-759-2606
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX701468363L00000X
TXAP120969363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX290394002Medicaid
TXTXB148094Medicare PIN
TX363084YKVAMedicare PIN