Provider Demographics
NPI:1205167129
Name:MARSHALL, KAREN (PA)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 SW COMMERCE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-1505
Mailing Address - Country:US
Mailing Address - Phone:386-755-2240
Mailing Address - Fax:386-755-6598
Practice Address - Street 1:426 SW COMMERCE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1505
Practice Address - Country:US
Practice Address - Phone:386-755-2240
Practice Address - Fax:386-755-6598
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105345363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002200000Medicaid