Provider Demographics
NPI:1275616823
Name:MARSH, DEBRA VICKERS (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:VICKERS
Last Name:MARSH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 WOODBRIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311
Mailing Address - Country:US
Mailing Address - Phone:304-347-4114
Mailing Address - Fax:304-347-4114
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHAS
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-4077
Practice Address - Fax:304-388-9852
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26614163W00000X
WV034015367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV430069471OtherMEDICARE RR
WV0065461000Medicaid
WVMA7297001Medicare ID - Type Unspecified