Provider Demographics
NPI:1942507207
Name:BOTHUN, MARISSA B (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:B
Last Name:BOTHUN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:B
Other - Last Name:BOTHUN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1790 N STONEBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-7437
Mailing Address - Country:US
Mailing Address - Phone:972-390-9002
Mailing Address - Fax:214-491-3777
Practice Address - Street 1:1790 N STONEBRIDGE DR
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-7437
Practice Address - Country:US
Practice Address - Phone:972-390-9002
Practice Address - Fax:214-491-3777
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07230363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant