Provider Demographics
NPI:1689009573
Name:REESE, MARISA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:REESE
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 1:9390 E CENTRAL AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2533
Mailing Address - Country:US
Mailing Address - Phone:316-733-4747
Mailing Address - Fax:316-733-5253
Practice Address - Street 1:9390 E CENTRAL AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2533
Practice Address - Country:US
Practice Address - Phone:316-733-4747
Practice Address - Fax:316-733-5253
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-03785363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant