Basic Information
| Provider Information | |||||||||
| NPI: | 1952854721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9073991717 | ||||||||
| Practice Location | |||||||||
| Address1: | 11701-32 SAN JOSE BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322230756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048800911 | ||||||||
| FaxNumber: | 9048809388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2016 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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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 | 363A00000X | PA9109612 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.