Provider Demographics
NPI:1174607600
Name:MCKIBBAN, MARISA H (PA)
Entity type:Individual
Prefix:MS
First Name:MARISA
Middle Name:H
Last Name:MCKIBBAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:GATTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:104 SOUTH AVE W
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-2652
Mailing Address - Country:US
Mailing Address - Phone:609-320-1302
Mailing Address - Fax:973-470-3506
Practice Address - Street 1:300 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2819
Practice Address - Country:US
Practice Address - Phone:973-470-3000
Practice Address - Fax:973-470-3506
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00167000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ107045TLMMedicare PIN