Provider Demographics
NPI:1225266414
Name:FAST, MARISSA ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:ANNE
Last Name:FAST
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 1:10 CENTENNIAL DR
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-7938
Mailing Address - Country:US
Mailing Address - Phone:978-535-1110
Mailing Address - Fax:978-535-5910
Practice Address - Street 1:10 CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-7938
Practice Address - Country:US
Practice Address - Phone:978-535-1110
Practice Address - Fax:978-535-5910
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP01709208000000X
MA250584208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics