Provider Demographics
NPI:1114269735
Name:BLACK, MARISSA (MD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11521 NE 128TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4317
Mailing Address - Country:US
Mailing Address - Phone:425-899-6800
Mailing Address - Fax:425-899-6818
Practice Address - Street 1:11521 NE 128TH ST STE 100
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034
Practice Address - Country:US
Practice Address - Phone:425-899-6800
Practice Address - Fax:425-899-6818
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60371542207RG0300X
WAMD60571983207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine