Provider Demographics
NPI:1518113570
Name:AMBRON, MARISSA LARA (DO)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:LARA
Last Name:AMBRON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MARISSA
Other - Middle Name:LARA
Other - Last Name:WEAKNECHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:SUITE 1K
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 HIGH STREET
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3198
Practice Address - Country:US
Practice Address - Phone:570-321-2850
Practice Address - Fax:570-321-2851
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0012720207R00000X
PAOS014928207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist