Provider Demographics
NPI:1255766531
Name:LIVERIS, MARISSA (PA-C)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:LIVERIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 E HURON ST STE 1-200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2909
Mailing Address - Country:US
Mailing Address - Phone:312-503-3576
Mailing Address - Fax:
Practice Address - Street 1:3825 HIGHLAND AVE STE 2B
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1548
Practice Address - Country:US
Practice Address - Phone:224-715-7485
Practice Address - Fax:630-852-4050
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085004770363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant