Provider Demographics
NPI:1497427702
Name:ALTMEYER, MARISSA NICHOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICHOLE
Last Name:ALTMEYER
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 1:991 ROUTE 19 N STE B
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16441-9739
Mailing Address - Country:US
Mailing Address - Phone:814-877-8790
Mailing Address - Fax:814-877-8792
Practice Address - Street 1:991 ROUTE 19 N STE B
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:PA
Practice Address - Zip Code:16441-9739
Practice Address - Country:US
Practice Address - Phone:814-877-8790
Practice Address - Fax:814-877-8792
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062750363AM0700X
PAOA006297363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA062750OtherMEDICAL PA LICENSE