=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417036492
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISA LEE HUGHES PA C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 166 SAXER AVE SPRINGFIELD SPORT EMERGENCY MEDICAL CORP
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-328-7262
-----------------------------------------------------
Fax | 610-328-4440
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 166 SAXER AVENUE
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-328-7262
-----------------------------------------------------
Fax | 610-328-4440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0A002059
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------