Provider Demographics
NPI:1477302164
Name:MATTHEWS, MARISA ALEXANDRA
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:ALEXANDRA
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 ROCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-4621
Mailing Address - Country:US
Mailing Address - Phone:860-329-5818
Mailing Address - Fax:
Practice Address - Street 1:41 BREWSTER RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5161
Practice Address - Country:US
Practice Address - Phone:860-585-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant