Provider Demographics
NPI:1780933267
Name:MARYNIAK, THOMAS D (PA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:MARYNIAK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 OVERLOOK TER
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2254
Mailing Address - Country:US
Mailing Address - Phone:608-256-1901
Mailing Address - Fax:
Practice Address - Street 1:1670 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2937
Practice Address - Country:US
Practice Address - Phone:608-356-9318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004408363A00000X
FLPA9107786363A00000X
DCPA031016363AM0700X
NY017987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical