Provider Demographics
NPI:1477132421
Name:ABBOTT MARIN, ANN REBECCA (DO)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:REBECCA
Last Name:ABBOTT MARIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 LEES SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64139-1236
Mailing Address - Country:US
Mailing Address - Phone:816-404-4862
Mailing Address - Fax:
Practice Address - Street 1:1296 JEFFCO BLVD
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-2138
Practice Address - Country:US
Practice Address - Phone:636-321-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2024032114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2024032114OtherLICENSE