Basic Information
| Provider Information | |||||||||
| NPI: | 1346484763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | TRISTA | ||||||||
| MiddleName: | JACINTA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3022 CASTLEWOODS DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312041474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783612822 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3351 NORTHSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312102587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782016500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2009 | ||||||||
| LastUpdateDate: | 03/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 068927 | GA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 068927 | 01 | GA | GA LICENSE | OTHER |