Provider Demographics
NPI:1457375032
Name:EDWARDS, MARISSA ANN (PAC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:ANN
Other - Last Name:COLYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:126 WARM SUNDAY WAY
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-3802
Mailing Address - Country:US
Mailing Address - Phone:814-386-1885
Mailing Address - Fax:
Practice Address - Street 1:49 PRINCE ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-3113
Practice Address - Country:US
Practice Address - Phone:717-901-3440
Practice Address - Fax:717-901-3447
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZT-632363A00000X
PAMA060596363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ121578Medicare PIN