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General NPI Number Information
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NPI Number | 1588225338
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Entity Type | Individual
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Provider Name | MARISSA CALLICOTTE PA-C
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Gender | Female
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Dates
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Enumeration Date | 06/24/2019
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Last Update Date | 07/29/2019
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Provider Practice Location Address
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Address Line | 8765 LEWIS AVE
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City | TEMPERANCE
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State | MI
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Zip | 48182-9300
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Country | US
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Telephone | 734-654-2169
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Fax |
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Provider Business Mailing Address
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Address Line | 120 MARSHALL DR
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City | SWANTON
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State | OH
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Zip | 43558-1422
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Country | US
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Telephone | 567-694-9394
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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 | 50.006009RX
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601009570
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License Number State | MI
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