Provider Demographics
NPI:1770531592
Name:COLE, MARVIN WAYNE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:WAYNE
Last Name:COLE
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
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Mailing Address - Street 1:27021 CAMBRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-7627
Mailing Address - Country:US
Mailing Address - Phone:253-859-3818
Mailing Address - Fax:253-859-3914
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Practice Address - Street 2:9040 REID ST
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-1162
Practice Address - Fax:253-968-1888
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAPA10002607363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA10002607OtherSTATE PROVIDER LICENSE