Provider Demographics
NPI:1356569461
Name:WEST, MARVIN R (PA)
Entity type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:R
Last Name:WEST
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8942 ELIZABETH FALLS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-5379
Mailing Address - Country:US
Mailing Address - Phone:904-891-0958
Mailing Address - Fax:
Practice Address - Street 1:10175 FORTUNE PKWY UNIT 803
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6754
Practice Address - Country:US
Practice Address - Phone:904-374-0353
Practice Address - Fax:904-503-0982
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 1584363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE0757YMedicare ID - Type Unspecified