Healthcare Provider Details

I. General information

NPI: 1275831471
Provider Name (Legal Business Name): MARISA ANN AKINBOLA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 N BALLAS RD
SAINT LOUIS MO
63131-2329
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8072
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-5225
  • Fax: 314-991-0943
Mailing address:
  • Phone: 314-996-5225
  • Fax: 314-991-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2017023561
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: