Provider Demographics
NPI:1437633070
Name:REIT, MARISSA RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:RAE
Last Name:REIT
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 1:10770 SE 173RD ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-6851
Mailing Address - Country:US
Mailing Address - Phone:352-435-7321
Mailing Address - Fax:
Practice Address - Street 1:10770 SE 173RD ST
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-6851
Practice Address - Country:US
Practice Address - Phone:352-435-7321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111557363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant