Healthcare Provider Details

I. General information

NPI: 1134849953
Provider Name (Legal Business Name): MARISSA MCBURNIE PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BROAD ST
CENTRAL FALLS RI
02863-1507
US

IV. Provider business mailing address

5050 WASHINGTON ST APT 216
WEST ROXBURY MA
02132-4744
US

V. Phone/Fax

Practice location:
  • Phone: 401-722-0081
  • Fax:
Mailing address:
  • Phone: 203-908-5196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA01647
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: