Healthcare Provider Details

I. General information

NPI: 1598099806
Provider Name (Legal Business Name): MARISSA P TAYLOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 GRAVOIS RD STE 210
FENTON MO
63026-7723
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 636-660-9850
  • Fax: 636-660-9851
Mailing address:
  • Phone: 314-851-1000
  • Fax: 314-851-4477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085003595
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2010014127
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: