Provider Demographics
NPI:1851011852
Name:MULDER, MARISSA (CRNA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MULDER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9259 W DENTON LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-3303
Mailing Address - Country:US
Mailing Address - Phone:916-955-4725
Mailing Address - Fax:
Practice Address - Street 1:9500 E IRONWOOD SQUARE DR
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4582
Practice Address - Country:US
Practice Address - Phone:480-626-2552
Practice Address - Fax:482-626-2552
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ280087367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered