Healthcare Provider Details

I. General information

NPI: 1851024061
Provider Name (Legal Business Name): MARISSA ANNA REDMOND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 COLLINS ST
AVON NY
14414-1466
US

IV. Provider business mailing address

470 COLLINS ST
AVON NY
14414-1466
US

V. Phone/Fax

Practice location:
  • Phone: 585-226-2640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number031016
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: