Provider Demographics
NPI:1700628039
Name:MARCELLUS, RUTH YAMILE
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:YAMILE
Last Name:MARCELLUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:
Other - Last Name:DEGAND MARCELLUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9423 N 17TH AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-0941
Mailing Address - Country:US
Mailing Address - Phone:860-884-6285
Mailing Address - Fax:
Practice Address - Street 1:9423 N 17TH AVE APT 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-0941
Practice Address - Country:US
Practice Address - Phone:860-884-6285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10390363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant