Provider Demographics
NPI:1376898544
Name:SPEER, MARISA JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:JEAN
Last Name:SPEER
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 1:844 OLD TUNNEL RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-8524
Mailing Address - Country:US
Mailing Address - Phone:530-274-9762
Mailing Address - Fax:
Practice Address - Street 1:844 OLD TUNNEL RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-8524
Practice Address - Country:US
Practice Address - Phone:530-274-9762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58680363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant