Provider Demographics
NPI:1588225338
Name:CALLICOTTE, MARISSA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:CALLICOTTE
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 1:120 MARSHALL DR
Mailing Address - Street 2:
Mailing Address - City:SWANTON
Mailing Address - State:OH
Mailing Address - Zip Code:43558-1422
Mailing Address - Country:US
Mailing Address - Phone:567-694-9394
Mailing Address - Fax:
Practice Address - Street 1:8765 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-9300
Practice Address - Country:US
Practice Address - Phone:734-654-2169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006009RX363A00000X
MI5601009570363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant