Provider Demographics
NPI:1134878663
Name:ELLISON, MARSHALL
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
Last Name:ELLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 V ST STE 1102
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1460
Mailing Address - Country:US
Mailing Address - Phone:916-734-3331
Mailing Address - Fax:
Practice Address - Street 1:4150 V ST STE 1102
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1460
Practice Address - Country:US
Practice Address - Phone:916-734-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program