Provider Demographics
NPI:1477185171
Name:POOTS, MARISSA KATE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:KATE
Last Name:POOTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:KATE
Other - Last Name:BREIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2723 WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-7131
Mailing Address - Country:US
Mailing Address - Phone:612-719-8104
Mailing Address - Fax:
Practice Address - Street 1:1428 2ND AVE N
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-4119
Practice Address - Country:US
Practice Address - Phone:515-574-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant