Provider Demographics
NPI:1598099806
Name:TAYLOR, MARISSA P (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:P
Last Name:TAYLOR
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:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-851-1000
Mailing Address - Fax:314-851-4477
Practice Address - Street 1:714 GRAVOIS RD STE 210
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-7723
Practice Address - Country:US
Practice Address - Phone:636-660-9850
Practice Address - Fax:636-660-9851
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003595363AM0700X
MO2010014127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical