Provider Demographics
NPI:1457527343
Name:MARSTALL, JACQUELINE E (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:E
Last Name:MARSTALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 HOMEFIELD RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-4757
Mailing Address - Country:US
Mailing Address - Phone:636-240-3529
Mailing Address - Fax:
Practice Address - Street 1:2175 CHARBONIER RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-5566
Practice Address - Country:US
Practice Address - Phone:314-831-5999
Practice Address - Fax:314-831-9434
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003004587363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant