Provider Demographics
NPI:1811593775
Name:EDWARDS, MARISSA NICOLE (CPNP-PC)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOLE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:MRS
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:BIDWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6711 TOWPATH RD STE 235
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9509
Mailing Address - Country:US
Mailing Address - Phone:315-471-2646
Mailing Address - Fax:315-471-1762
Practice Address - Street 1:6711 TOWPATH RD STE 235
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9509
Practice Address - Country:US
Practice Address - Phone:315-471-2646
Practice Address - Fax:315-471-1762
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF383174-01363LP0200X
NYF383174363LP0200X
NY383174363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics