Provider Demographics
NPI:1972834364
Name:MARIETTA, NEESANN (MD)
Entity Type:Individual
Prefix:DR
First Name:NEESANN
Middle Name:
Last Name:MARIETTA
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 1:6460 E GRANT RD # 32692
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-8800
Mailing Address - Country:US
Mailing Address - Phone:520-230-7805
Mailing Address - Fax:901-200-4262
Practice Address - Street 1:5301 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2805
Practice Address - Country:US
Practice Address - Phone:520-230-7805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2023-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ47759207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1972834364Medicaid