Provider Demographics
NPI:1831865534
Name:DOLL, MARISA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:ROSE
Last Name:DOLL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:BALBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:101 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4870
Mailing Address - Country:US
Mailing Address - Phone:631-745-2857
Mailing Address - Fax:
Practice Address - Street 1:527 BOULEVARD E
Practice Address - Street 2:
Practice Address - City:YAPHANK
Practice Address - State:NY
Practice Address - Zip Code:11980-7512
Practice Address - Country:US
Practice Address - Phone:631-504-0427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-22
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY027122363A00000X
SC5585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant