Basic Information
| Provider Information | |||||||||
| NPI: | 1164751319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | COLIN | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013875300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 N 400 E | ||||||||
| Address2: | |||||||||
| City: | PANGUITCH | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847597803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356762252 | ||||||||
| FaxNumber: | 4356761544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2009 | ||||||||
| LastUpdateDate: | 08/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 361780-1204 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1164751319 | 05 | UT | MEDICAID |