Provider Demographics
NPI:1366940132
Name:MARSHALL, HOGAN NICKLAUS (AT)
Entity type:Individual
Prefix:
First Name:HOGAN
Middle Name:NICKLAUS
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 SCARLET OAK DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:OH
Mailing Address - Zip Code:45050-2520
Mailing Address - Country:US
Mailing Address - Phone:513-335-2656
Mailing Address - Fax:
Practice Address - Street 1:7118 MOUNT ROYAL AVE
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082
Practice Address - Country:US
Practice Address - Phone:614-797-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0056442255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAT005644OtherOTPTAT LICENSURE BOARD
2000031812OtherBOARD OF CERTIFICATION