Provider Demographics
NPI:1912408337
Name:MARVIN, LAUREN YVONNE (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:YVONNE
Last Name:MARVIN
Suffix:
Gender:F
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 1:93 BLUEBERRY HILL RESERVE
Mailing Address - Street 2:
Mailing Address - City:KILLINGWORTH
Mailing Address - State:CT
Mailing Address - Zip Code:06419-2330
Mailing Address - Country:US
Mailing Address - Phone:860-304-5003
Mailing Address - Fax:
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606
Practice Address - Country:US
Practice Address - Phone:203-576-5877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6456363A00000X
CT4092363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant