Provider Demographics
NPI:1013146257
Name:SHUFFIELD, MARISSA M (PA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:M
Last Name:SHUFFIELD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 FORT WORTH HWY
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-4779
Mailing Address - Country:US
Mailing Address - Phone:817-598-5620
Mailing Address - Fax:817-598-5621
Practice Address - Street 1:2005 FORT WORTH HWY
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-4779
Practice Address - Country:US
Practice Address - Phone:817-598-5620
Practice Address - Fax:817-598-5621
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06234363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L18007Medicare PIN
TX8L18008Medicare PIN
TX8L18009Medicare PIN