Healthcare Provider Details

I. General information

NPI: 1275210767
Provider Name (Legal Business Name): MARISSA C MCCLEMENT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SEYMOUR ST STE 919
HARTFORD CT
06106-5528
US

IV. Provider business mailing address

85 SEYMOUR ST STE 919
HARTFORD CT
06106-5528
US

V. Phone/Fax

Practice location:
  • Phone: 860-696-5520
  • Fax:
Mailing address:
  • Phone: 860-696-5520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number006695
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: