Provider Demographics
NPI:1629165956
Name:SHIH, MARISSA EUSEBIO (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:EUSEBIO
Last Name:SHIH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 ROCKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9415
Mailing Address - Country:US
Mailing Address - Phone:606-436-5761
Mailing Address - Fax:606-436-5797
Practice Address - Street 1:115 ROCKWOOD LN
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9415
Practice Address - Country:US
Practice Address - Phone:606-436-5761
Practice Address - Fax:606-436-5797
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3180P363LF0000X
KY3003180363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78004215Medicaid
KY61-0991301OtherCORPORATION TAX ID
KY61-0991301OtherCORPORATION TAX ID
KYP14093Medicare UPIN