Provider Demographics
NPI:1710154521
Name:MCKISSICK, MARIANNE DOLORES (PAC)
Entity Type:Individual
Prefix:MRS
First Name:MARIANNE
Middle Name:DOLORES
Last Name:MCKISSICK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
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Mailing Address - Street 1:3350 GRATIOT BLVD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-2121
Mailing Address - Country:US
Mailing Address - Phone:810-364-4000
Mailing Address - Fax:810-364-5995
Practice Address - Street 1:3350 GRATIOT BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-2121
Practice Address - Country:US
Practice Address - Phone:810-364-4000
Practice Address - Fax:810-364-5995
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003532363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant