Provider Demographics
NPI:1881778892
Name:HERRICK, MARLO (PA-C)
Entity type:Individual
Prefix:
First Name:MARLO
Middle Name:
Last Name:HERRICK
Suffix:
Gender:
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 1:31 OLD ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-1711
Mailing Address - Country:US
Mailing Address - Phone:475-253-2599
Mailing Address - Fax:
Practice Address - Street 1:31 OLD ROUTE 7
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-1711
Practice Address - Country:US
Practice Address - Phone:475-253-2599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA8217363AM0700X
NY027021363AM0700X
CT000631363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000631OtherCT LICENSE