Provider Demographics
NPI:1073212833
Name:BUCHANAN, MARISSA (NP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:4909 GREAT RIVER DR.
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4909 GREAT RIVER DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305
Practice Address - Country:US
Practice Address - Phone:601-282-8980
Practice Address - Fax:601-693-6561
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905834363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily