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General NPI Number Information
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NPI Number | 1275204810
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Entity Type | Individual
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Provider Name | MARISSA LYNNE WALASZEK PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/23/2021
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Last Update Date | 09/23/2021
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Provider Practice Location Address
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Address Line | 855 COSHOCTON AVE # H
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City | MOUNT VERNON
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State | OH
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Zip | 43050-1975
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Country | US
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Telephone | 740-326-6552
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 147
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City | SAINT LOUISVILLE
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State | OH
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Zip | 43071-0147
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Country | US
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Telephone | 614-557-9159
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50.007257RX
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License Number State | OH
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