Provider Demographics
NPI:1326817222
Name:PERKINS, MARISSA NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOLE
Last Name:PERKINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4310
Mailing Address - Country:US
Mailing Address - Phone:260-388-4366
Mailing Address - Fax:
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4160
Practice Address - Country:US
Practice Address - Phone:260-435-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004304A363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program