Basic Information
| Provider Information | |||||||||
| NPI: | 1275556904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | MARSHALL | ||||||||
| MiddleName: | KEITH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 520 N 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993015257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094168849 | ||||||||
| FaxNumber: | 5095423059 | ||||||||
| Practice Location | |||||||||
| Address1: | 5304 ROAD 68 | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993018078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095439300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | NE229 | NE | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 7914 | SD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MT28430 | MT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 9500A | WY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | O-0812 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OP60488723 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 06908 | 01 | NE | BCBS | OTHER |