Healthcare Provider Details

I. General information

NPI: 1588225338
Provider Name (Legal Business Name): MARISSA CALLICOTTE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8765 LEWIS AVE
TEMPERANCE MI
48182-9300
US

IV. Provider business mailing address

120 MARSHALL DR
SWANTON OH
43558-1422
US

V. Phone/Fax

Practice location:
  • Phone: 734-654-2169
  • Fax:
Mailing address:
  • Phone: 567-694-9394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006009RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601009570
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: