Healthcare Provider Details

I. General information

NPI: 1699552109
Provider Name (Legal Business Name): MARISSA ERIN BACKHAUS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA MCKEEHAN

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 3RD ST SE
LOVELAND CO
80537-6419
US

IV. Provider business mailing address

8450 ARISTA PL APT 316
BROOMFIELD CO
80021-4177
US

V. Phone/Fax

Practice location:
  • Phone: 970-669-4855
  • Fax:
Mailing address:
  • Phone: 920-562-8830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: