Provider Demographics
NPI:1184794364
Name:CARLISI, MARIANNA B (PA)
Entity type:Individual
Prefix:
First Name:MARIANNA
Middle Name:B
Last Name:CARLISI
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 1:205 N TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06854-1123
Mailing Address - Country:US
Mailing Address - Phone:718-920-4058
Mailing Address - Fax:718-798-0730
Practice Address - Street 1:MMC - EMERGENCY MEDICINE
Practice Address - Street 2:111 EAST 210TH STREET
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-4058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6187363AM0700X
CT2679363AM0700X
NY006187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical