Provider Demographics
NPI:1861470338
Name:MCCLINTOCK, MARISSA JODI (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:JODI
Last Name:MCCLINTOCK
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 1:107 CAYUGA HEIGHTS RD
Mailing Address - Street 2:APT 11
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-2152
Mailing Address - Country:US
Mailing Address - Phone:617-990-4085
Mailing Address - Fax:
Practice Address - Street 1:107 CAYUGA HEIGHTS RD
Practice Address - Street 2:APT 11
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-2152
Practice Address - Country:US
Practice Address - Phone:617-990-4085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011434363A00000X
MA1812363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q21408Medicare UPIN
MAAP2181Medicare ID - Type Unspecified