Healthcare Provider Details

I. General information

NPI: 1023727146
Provider Name (Legal Business Name): MARISSA ELIZABETH BAUMGARTNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA ELIZABETH GEYER

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49725 COUNTY 83
STAPLES MN
56479-5280
US

IV. Provider business mailing address

49725 COUNTY 83
STAPLES MN
56479-5280
US

V. Phone/Fax

Practice location:
  • Phone: 218-894-1515
  • Fax: 218-894-8403
Mailing address:
  • Phone: 218-894-1515
  • Fax: 218-894-8403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14291
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: