Provider Demographics
NPI:1669849451
Name:MASSE, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:MASSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22101 MOROSS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-4273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI5601007584363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant