Provider Demographics
NPI:1144768466
Name:MUTZEK, MARISSA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOLE
Last Name:MUTZEK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BLUEBERRY DR.
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337
Mailing Address - Country:US
Mailing Address - Phone:570-269-9876
Mailing Address - Fax:
Practice Address - Street 1:105 BLUEBERRY DR # 90
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18337-9015
Practice Address - Country:US
Practice Address - Phone:570-269-9876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058716363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical