Healthcare Provider Details

I. General information

NPI: 1366932907
Provider Name (Legal Business Name): MARISSA L TAGGART PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA MERTENS PA

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 BROADWAY
KINGSTON NY
12401-4626
US

IV. Provider business mailing address

114 LANTERN RD
HICKSVILLE NY
11801-6210
US

V. Phone/Fax

Practice location:
  • Phone: 845-331-3131
  • Fax:
Mailing address:
  • Phone: 516-644-0410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: