Provider Demographics
NPI:1053398578
Name:MARCIANO, PATRICIA N (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:N
Last Name:MARCIANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:N
Other - Last Name:MARCIANO-LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 8007
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-0507
Mailing Address - Country:US
Mailing Address - Phone:208-883-2224
Mailing Address - Fax:208-883-6580
Practice Address - Street 1:2500 W A ST STE 101
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-6000
Practice Address - Country:US
Practice Address - Phone:208-882-2011
Practice Address - Fax:208-883-1853
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1053398578Medicaid
IN200489840Medicaid
7367603OtherAETNA
IN15684OtherPHYSICIANS HEALTH PLAN
IN3937240015OtherMEDICARE DMEPOS
INP00244862OtherRAILROAD MEDICARE
IN200489840Medicaid
IN069880LMedicare PIN
IN252060C5Medicare PIN
IN130910AAAMedicare PIN
I17636Medicare UPIN
IN941090CC4Medicare PIN
IN3937240015OtherMEDICARE DMEPOS