Provider Demographics
NPI:1467999169
Name:WEN, MARISSA M (MD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:M
Last Name:WEN
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 1:1507 GARDEN FARMS AVE
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-8292
Mailing Address - Country:US
Mailing Address - Phone:626-589-7899
Mailing Address - Fax:
Practice Address - Street 1:1507 GARDEN FARMS AVE
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330-8292
Practice Address - Country:US
Practice Address - Phone:209-479-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA161459207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty