Basic Information
| Provider Information | |||||||||
| NPI: | 1154646248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAULDS | ||||||||
| FirstName: | MARSHALL | ||||||||
| MiddleName: | COLIN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10251 STRADA LATERINA CT | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891352527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025759339 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1145 STURGIS ROAD | ||||||||
| Address2: | |||||||||
| City: | TWENTYNINE PALMS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922788275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608302117 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2010 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA2014-14 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.