Provider Demographics
NPI:1740248327
Name:NORMAN, MARC A (PAC)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:NORMAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:561 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1410
Practice Address - Country:US
Practice Address - Phone:740-369-8711
Practice Address - Fax:740-368-5050
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001224363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00139024OtherRAILROAD MEDICARE
P05063Medicare UPIN
OHP00139024OtherRAILROAD MEDICARE