MEDICARE: MISS MARISSA MCCLEVE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	5601008789	MI

General Provider Information

NPI Number	:	1467937102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MARISSA MCCLEVE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 1847
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49443-1847
Country	:	US
Telephone Number	:	231-728-1663
Fax Number	:	231-728-4789

Provider Business Practice Location Address
First Line	:	1675 LEAHY ST STE 401A
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49442-5547
Country	:	US
Telephone Number	:	231-727-4243
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2018
Last Update Date	:	09/09/2019

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