MEDICARE: MARISSA JODI MCCLINTOCK 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	011434	NY
2	363AS0400X	Surgical Physician Assistant	1812	MA

General Provider Information

NPI Number	:	1861470338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA JODI MCCLINTOCK PA-C

Provider Business Mailing Address
First Line	:	107 CAYUGA HEIGHTS RD
Second Line	:	APT 11
City	:	ITHACA
State	:	NY
Zip	:	14850-2152
Country	:	US
Telephone Number	:	617-990-4085
Fax Number	:

Provider Business Practice Location Address
First Line	:	107 CAYUGA HEIGHTS RD
Second Line	:	APT 11
City	:	ITHACA
State	:	NY
Zip	:	14850-2152
Country	:	US
Telephone Number	:	617-990-4085
Fax Number	:

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

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	10/10/2007

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