Provider Demographics
NPI:1366932907
Name:MERTENS, MARISSA L (PA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:L
Last Name:MERTENS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 LANTERN RD
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-6210
Mailing Address - Country:US
Mailing Address - Phone:516-644-0410
Mailing Address - Fax:
Practice Address - Street 1:396 BROADWAY
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-4626
Practice Address - Country:US
Practice Address - Phone:845-331-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant