Provider Demographics
NPI:1881690485
Name:MUSCAT, MARISSA ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:ROSE
Last Name:MUSCAT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:2170 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7026
Practice Address - Country:US
Practice Address - Phone:530-541-3420
Practice Address - Fax:530-541-8723
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81313207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H75385Medicare UPIN
CA1881690485Medicaid
NV1881690485Medicaid
CA00A813130Medicare PIN
NVV39794Medicare PIN