Deatherage, Marina

Deatherage, Marina is an individual health care provider with primary practice located at 146 E Geneva Sq , Lake Geneva WI 53147-9694. She recently has 2 registered licenses in different health care specialties including Physician Assistants & Advanced Practice Nursing Providers / Family, Physician Assistants & Advanced Practice Nursing Providers / Nurse Practitioner. Physician Assistants & Advanced Practice Nursing Providers / Nurse Practitioner is her primary health care specialty. Deatherage, Marina can be contacted via phone (262) 249-4660.

Contact Information

Primary practice address
146 E Geneva Sq Lake Geneva WI 53147-9694
Phone: (262) 249-4660
Fax:
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Physician Assistants & Advanced Practice Nursing Providers / Family 363LF0000X 209020317 Illinois
Physician Assistants & Advanced Practice Nursing Providers / Nurse Practitioner 363L00000X 10857-033 Wisconsin

Profile Details

NPI number 1538706858
LBN Legal business name Deatherage, Marina
Credentials
Entity Individual
Sole proprietor 1 No
Enumeration date Dec 5th, 2019
Last updated Nov 30th, 2021 - about 3 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1538706858 NPPES
Wisconsin MEDICAID 100162164

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