Provider Demographics
NPI:1114957198
Name:MCKISSACK, MARINA MONTSERRAT (PA-C)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:MONTSERRAT
Last Name:MCKISSACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARINA
Other - Middle Name:MONTSERRAT
Other - Last Name:SHEPHERDSON-SANTIAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2251 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-6710
Mailing Address - Country:US
Mailing Address - Phone:715-361-2000
Mailing Address - Fax:
Practice Address - Street 1:2251 NORTH SHORE DR
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501
Practice Address - Country:US
Practice Address - Phone:715-361-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1827-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q26816Medicare UPIN