Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1295233468 |
---|---|
Provider Name | Matthew Marshall |
First Address | Overland, MO 63114-4825 |
Second Address | Saint Louis, MO 63139-2935 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2018 |
Last Update Date | 17/09/2021 |